260125_Chapter_1B_-_Attachment_PBM_Questionnaires_(MOA_and_QE)-RETURN_WITH_BID.xlsx
XLSX spreadsheet 36 KB Posted
- Solicitation number
- 260125
- Issued by
- Pima County, Tucson City, Arizona
About this file
This is a Pharmacy Benefit Manager (PBM) Questionnaire for the City of Tucson, Arizona, part of RFP #260125. The document is a comprehensive questionnaire requiring detailed responses from potential PBM vendors across multiple sections including Method of Approach, Qualifications and Experience, and Performance Guarantees. The solicitation seeks a pharmacy benefit management services provider to manage prescription drug benefits for the city, with a focus on Medicare Part D coverage, customer service capabilities, reporting requirements, communication processes, and detailed operational performance metrics.
The questionnaire includes extensive requirements for vendors to demonstrate their capabilities, including financial stability, account management expertise, reporting tools, member communication strategies, and specific performance guarantees. Key performance metrics include claims processing accuracy (99.9%), mail order and specialty pharmacy turnaround times (2-4 business days), enrollment data updates within one business day, and implementation accuracy. Vendors must provide detailed information about their organizational structure, customer service approach, Medicare compliance, outsourced services, current client base, and ability to customize reporting and communication for the City of Tucson's specific needs. The document indicates the city is seeking a comprehensive, technologically advanced PBM solution with robust reporting and member service capabilities.
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Questionnaire Instructions
| Questionnaire Instructions to Offerors: |
| ***DO NOT ALTER THE QUESTIONS OR QUESTION NUMBERING***. |
Offerors shall complete all Questionnaires, including the separate 2025 PBM RFP Questionnaire City of Tucson Excel spreadsheet Pricing Documents, and Cost Exhibits included in this solicitation, in the format indicated. Sections shall not be left blank or with a reference to find answer(s) elsewhere in the proposal. All cost items must be included and reflected only on the appropriate Pricing Document.
| If you cannot comply or will not comply with all requirements outlined in this pharmacy solicitation, include a detailed description on the DEVIATIONS page. Include the section name, citation number, and a description of the deviation. |
| Lengthy responses are less preferred. To avoid this, be concise in your response. Use bullet points as appropriate. Reconsider how to word any response that exceeds 500 words in length so that the response contains the most important points you want displayed. Do not refer the reader to an appendix/attachment for further information unless directed. Vendors will be held accountable for the accuracy and validity of all answers. |
NOTE: Please make sure to provide an electronic copy of your completed questionnaire in Word or Excel Format. You may include a PDF version; however, the Word or Excel versions are critical to completing the analysis.
&"-,Bold"&14RFP #260125 Attachment 1B - Pharmacy
&"-,Bold"&10&F&"-,Regular" Page &P
MOA Questionnaire
| METHOD OF APPROACH - GENERAL INFORMATION | OFFEROR RESPONSE | ||
| 1 | Organization: | ||
| 1a | Has your organization acquired, been acquired by, or merged with another organization in the past 24 months? | ||
| 1b | In order to meet ALL of the services in this Attachment are you including any subcontractors or partners in the delivery of ANY services to the City? If so, please list ALL subcontractors and partners including a list of services they will provide, their location and any fees that will be associated with their services. | ||
| 1c | Offshore: Identify any services under any subsequent contract that may be awarded as part of this RFP that are currently or planned to be performed outside the borders of the United States. | ||
| 2 | Litigation: | ||
| 2a | Is your organization involved in any current litigation against or from the City? If yes, please describe. | ||
| 2b | Has your organization been involved in litigation within the last five years arising out of its performance in the administration of a program similar to what your organization is proposing for the City of Tucson? Exclude routine matters involving participants that do not reflect on your organization’s performance under the contract with its client. If the answer is yes, explain fully. | ||
| 3 | Laws: | ||
| 3a | Explain how you stay current with changes in federal and state laws pertaining to the services you are proposing. | ||
| 3b | Confirm you agree to supply, upon request by the City, verification of compliance with any regulation stipulated herein or pursuant to any state or federal law. | ||
| 4 | Customer/Member Service: | ||
| 4a | Describe your company’s expectations for quality of customer service. | ||
| 4b | Describe your customer service capabilities. | ||
| 4c | How long will you retain member call recordings in the Member Call Center and how will the City obtain access to those recordings? | ||
| 4d | Confirm you will provide at a minimum a designated customer service team of representatives for the City and describe that team. | ||
| 4e | What is the average tenure of your customer service representatives? | ||
| 4f | Where is the customer service staff located that will service the City of Tucson account? | ||
| 4g | Do you agree to respond to account issues and member service issues within two business days maximum with a plan to resolve the issue within a specified timeframe established to do so? | ||
| 4h | Do you agree to provide documentation of a process for prompt issue resolution and maintain an issue log? | ||
| 4i | Do you provide members with limited English proficiency, Spanish-speaking, and those who are deaf or hearing impaired with access to communication services that enable them to utilize the phone lines? | ||
| 4j | Please detail your escalation process to assist in matters that cannot be resolved at the customer service unit level. | ||
| 5 | Medicare: | ||
| 5a | Do you self-administer prescription benefit management services for Part D coverage or do you outsource this function? | ||
| 5b | For drugs that overlap coverage between Medicare Part B and Medicare Part D, how do you ensure Part B covered drugs are reimbursed using Part B coverage and payment rules? | ||
| 5c | How will your Pharmacy & Therapeutics (P&T) Committee resolve coverage issues between the Plan’s formulary and the Employer Group’s special coverage? How will this be communicated in advance to the Employer Group? To Medicare members who are affected? | ||
| 5d | Describe how your PBM would work with a medical carrier to improve drug therapy management. | ||
| 5e | Do you self-administer prescription benefit management services for Part D coverage or do you outsource this function? | ||
| 5f | For drugs that overlap coverage between Medicare Part B and Medicare Part D, how do you ensure Part B covered drugs are reimbursed using Part B coverage and payment rules? | ||
| 5g | How will your Pharmacy & Therapeutics (P&T) Committee resolve coverage issues between the Plan’s formulary and the Employer Group’s special coverage? How will this be communicated in advance to the Employer Group? To Medicare members who are affected? | ||
| 5h | Describe how your PBM would work with a medical carrier to improve drug therapy management. | ||
| 5i | Are you willing to guarantee that the pharmacy network available to members under your plan will provide access in accordance with 100% of CMS access standards for Part D plans? | ||
| 5j | Describe how your plan meets CMS access standards for long-term care pharmacy, I/T/U pharmacy, home infusion pharmacy, and other specialty pharmacy programs. | ||
| 5k | Please include the Formulary(s) that is applicable to the Medicare plan offering. | ||
| 5l | Please advise if a Mail Order program is utilized in the Medicare plan offering. Please explain. | ||
| 5m | Please confirm that your prescription drug programs offering meet all CMS requirements. | ||
| 5n | How do you track TrOOP costs of Medicare members? | ||
| 5o | Is your Plan willing to generate reports on TrOOP costs of Medicare members enrolled in this plan including a breakdown of the sources of payment of such claims between the plan, supplementary coverage offered by the employer group, or payments by the Medicare member? | ||
| 6 | Outsourced Services | Outsourced (Y/N) | Subcontractor and Location |
| 6a | Claim Processing | ||
| 6b | Formulary Management | ||
| 6c | Appeals | ||
| 6d | Clinical Functions | ||
| 6e | Pharmacy & Therapeutics Committee | ||
| 6f | Customer Service | ||
| 6g | Rebate Contracting | ||
| 6h | Network Contracting | ||
| 6i | Mail Order | ||
| 6j | Specialty Pharmacy | ||
| 6k | Data Reporting | ||
| 7 | Contractor Profile | ||
| 7a | Total Number of Lives (2024) | ||
| 7b | Total Number of Scripts Dispensed (2024) | ||
| 7c | Total AWP Dollars Processed (2024) | ||
| 7d | Total Number of Pharmacy Benefit Client Accounts (2024) | ||
| 7e | Total Number of Full-Service Pharmacy Benefit Client Accounts over 5,000 covered lives (2024) | ||
| 8 | Customer Service Facility | ||
| 8a | Location | ||
| 8b | Days of Operation | ||
| 8c | Hours of Operation | ||
| 8d | Percent of Calls Abandoned | ||
| 8e | Average Number of Seconds to reach Customer Service Representative |
| METHOD OF APPROACH – REPORTING | OFFEROR RESPONSE | |
| 1 | Provide examples of your standard reporting package. (Label as Attachment 10 - Reporting Package). | |
| 2 | Provide examples of your presale modeling reporting. (Label as Attachment 11 - Modeling Report). | |
| 3 | Provide examples of your post-implementation reporting. (Label as Attachment 12 - Post-Implementation Report). | |
| 4 | Provide a copy of your ad hoc reporting tool report catalog that City of Tucson will be able to use (Label as Attachment 13 - Report Catalog). | |
| 5 | Provide a temporary login/password and instructions for accessing a demo of your online reporting tool. | |
| 6 | Describe your process for training City of Tucson users on how to use your online reporting tool. | |
| 7 | What kind of reports are accessible by the City through your online reporting too? | |
| 8 | Can the City and their designated consultant generate reports on their own or are reports delivered by secure website or email on a periodic basis? Please explain. | |
| 9 | How quickly will the City be able to run online reports or see claims data on a real-time basis? | |
| 10 | Indicate how many months of historical claims data are available via the online reporting tool and your willingness to load incumbent claim data for reporting purposes. | |
| 11 | Describe your ability to build customized reporting according to the needs of City of Tucson. | |
| 12 | Confirm you will provide quarterly and annual consultative pharmacy performance reviews to the City. | |
| 13 | Confirm what standard reports you are providing to the City at no additional cost. Please list those reports. | |
| 14 | The City is interested in obtaining their claims data in real-time or near real-time. Please explain how quickly the City can obtain claims payment information from your organization (e.g. daily, weekly, etc.). | |
| 15 | Confirm what hourly rate you will charge for Custom Ad hoc Reports. |
| METHOD OF APPROACH - COMMUNICATION | OFFEROR RESPONSE | |
| 1 | Indicate how you will personalize member communications based on City of Tucson’s various demographics (e.g., age, new hires) and type of enrolled plan. | |
| 2 | Provide a temporary login/password and instructions for accessing a demo of your member website. | |
| 3 | Provide information on programs your organization offers that would allow members to contact the same Care Representative. | |
| 4 | Describe your organization’s process for providing training to member service representatives to serve active and retiree membership. | |
| 5 | Describe how you track member complaints. List the top 5 member complaints related to retail, mail order, and the specialty pharmacy program. Describe the processes/remedies that have been put into effect to resolve these complaints. | |
| 6 | Describe how you use statistics with respect to customer and member service telephone response and abandonment times. Provide results for the last calendar year. | |
| 7 | How are disabled (e.g., hearing-impaired) member calls facilitated through your member services area? | |
| 8 | Provide a sample copy of your mail service communications materials that will be provided to City of Tucson members. (Label as Attachment 14 - Communication_Mail). | |
| 9 | Provide a sample copy of your specialty service communications materials that will be provided to City of Tucson members. (Label as Attachment 15 - Communication_Specialty). | |
| 10 | Provide a sample copy of your clinical program communications materials that will be provided to City of Tucson members. (Label as Attachment 16 - Communication_Clinical). | |
| 11 | Provide a sample copy of all communications materials used during the implementation (e.g., ID cards, welcome kits, formulary brochures, and other relevant materials) that will be provided to City of Tucson members. (Label as Attachment 17 - Communication_Other). |
&"-,Bold"&14RFP #260125 Attachment 1B - Pharmacy
&"-,Bold"&10&F&"-,Regular" Page &P
Q&E Questionnaire
| QUALIFICATIONS AND EXPERIENCE | OFFEROR RESPONSE | ||
| 1 | Organization: Please complete the following information about your organization: | ||
| 1a | Provide a Brief History | ||
| 1b | Date your firm became operational for the services requested in this Attachment | ||
| 1c | How many employees does your organization have? | ||
| 1d | In Arizona, what is the size of the staff that will service the City of Tucson? | ||
| 1e | How long have you been providing services requested in this Attachment to employers in Arizona? | ||
| 1f | Describe your experience providing services to other public sector employers in Arizona. | ||
| 1g | How many direct group plan sponsor clients do you currently service? | ||
| 1h | What is the average group size (covered employees/retirees)? | ||
| 1i | What proportion of your business is providing the coverage you are proposing? Other lines of group coverage you are not proposing? Please detail. | ||
| 1j | What are your long-term corporate objectives regarding your business with respect to the coverage you are proposing? | ||
| 1k | In what states are you NOT licensed to do business? | ||
| 1l | What certifications, accreditations, awards or recognition has your organization received? | ||
| 1m | What is your organization’s customer service philosophy? How do you ensure consistent implementation of the philosophy? | ||
| 1n | Please explain how you will ensure the City and their plan participants will receive exceptional service from your organization. Define exceptional service. | ||
| 1o | What key attributes distinguish your organization from your competitors? | ||
| 1p | How will the service you are proposing support the overall health and wellness of the City’s workforce? | ||
| 1q | How do you propose to alert the City’s key management and human resource staff regarding problem areas or trends identified? | ||
| 2 | Financials: | ||
| 2a | Provide your current rating and one prior rating for each entity holding any part of the insurance risk by the following agencies. If the ratings have changed, provide explanation. If you are not rated, provide a detailed explanation | Current | |
| Rating | Prior Rating | Date |
Changed
| 2ai | Standard and Poor’s (S&P) | ||||
| 2aii | Duff and Phelps | ||||
| 2aiii | A.M. Best | ||||
| 2aiv | Moody’s | ||||
| 2b | Within the last 24 months, has your organization been served or involved in a significant and/or class action lawsuit that might impact your rating? | ||||
| 2c | Describe any changes in the organizational structure (including, but not limited to, demutualization, addition/deletion of claim offices, addition/removal of product lines, and staff reductions) that have occurred in your organization over the last 12 months or are anticipated to occur in the next 24 months. | ||||
| 2d | Do you agree to promptly notify the City (Benefits Office and Procurement Office) of any change in your ownership or control affecting 10% or greater interest, any acquisition by you of 10% or greater interest in any subsidiary, and any new agreement with, by or between any affiliates that is relevant to this contract? | ||||
| 3 | Account Management: | ||||
| 3a | Designated Account Team: Provide the names, titles, resumes, locations, email addresses and phone numbers of all proposed key personnel including the Account Manager who will service the City’s account. Provide their respective qualifications and credentials and the capacity in which they will serve. | ||||
| 3b | Describe your account management team’s experience in providing services for similar entities including how they will be trained in the City’s plan issues, their accessibility to the City and their capacity and authority to respond to the City’s issues in a timely manner. | ||||
| 3c | Confirm you agree to provide the necessary staff for planning, transition, implementation, annual open enrollment(s), and/or any special open enrollments and ongoing administration of the plan at no additional cost to the City? | ||||
| 3d | Describe how you will meet ALL of the services currently performed by the Client Service Executive (Scope of Work: Pharmacy Benefit Manager (PBM). Please detail each service and identify who will be responsible. | ||||
| 4 | References: | ||||
| Current Client References (Similar Sized Arizona Clients Preferred) | |||||
| Client Name | Contact Name | Phone Number and Client Location | Number of Members | Contract Start Date | |
| 4a | |||||
| 4b | |||||
| 4c | |||||
| Recently Terminated Clients (Similar Sized Arizona Clients Preferred) | |||||
| Client Name | Contact Name | Phone Number and Client Location | Number of Members | Contract Start Date | |
| 4d | |||||
| 4e | |||||
| 4f |
| REPORTING | OFFEROR RESPONSE | |
| 1 | Consultative Analytics: Confirm you will provide an annual consultative analytics review of the pharmacy program and will include attendance by the PBM director if the City requests. | |
| 2 | Standard Reports: | |
| 2a | Confirm that at a minimum you are able to provide the reports identified in the Scope of Work section titled “Data and Reporting” and at the frequency rate requested at no additional cost to the City. | |
| 2b | List and provide sample copies of reports you will make available to the City. | |
| 2c | Can the City and their designated consultant generate reports on their own or are reports delivered by secure website or email on a periodic basis? Please explain. | |
| 3 | Real-Time Reporting: The City is interested in obtaining their claims data in real-time or near real-time. Please explain how quickly the City can obtain claims payment information from your organization (e.g. daily, weekly, etc.). | |
| 4 | Custom Reports: | |
| 4a | What types of other utilization and/or financial reports are available to the City? Please provide sample copies of these reports. | |
| 4b | How often can these reports be produced? | |
| 4c | What is the cost (if any) of these reports and any additional ad-hoc reports? | |
| 4d | What reports are accessible by the City through the Internet or on your website? | |
| 4e | Can the City or their consultant generate reports on their own or are reports delivered by secure FTP or email on a periodic basis? Please explain. |
&"-,Bold"&14RFP #260125 Attachment 1B - Pharmacy
&"-,Bold"&10RFP #260125 Attachment 1A - Medical Questionnaires &"-,Regular"Page &P
Performance Guarantees
| PERFORMANCE GUARANTEES | OFFEROR RESPONSE | ||
| For each of the following categories, provide the financial penalty (maximum dollar amount or % of administrative fees) you will agree to pay if the standard and method of measuring the penalty is not met. | Measurement Frequency | Target | Dollars at Risk |
(% or $)
| 1 | Implementation Set-up: 100% accuracy of Group Structure, Benefit Plan Design, and member portal system set-up 90 days before the plan effective date | One-Time | Pass / Fail |
| 2 | Implementation Eligibility Load: 100% system confirmation and report indicating clean load of eligibility files and/or documentation showing error resolution complete by 15 days before the plan effective date. | One-Time | Pass / Fail |
| 3 | Implementation Claims History and Prior Authorization (PA) Transfer: System confirmation of claims and PA history data load in Offeror system 90 days before the plan effective date. Additional PA file updates should occur 30 and 14 days prior to plan effective date and PA lag files loaded 7 and 14 days after the effective date. | One-Time | Pass / Fail |
| 4 | Implementation Testing: System confirmation of completion of testing and system set-up 30 days before the plan effective date. | One-Time | Pass / Fail |
| 5 | Implementation Approach Team: | One-Time | Pass / Fail |
| Follow an approved and executed work plan offering the following: | |||
| 5a | Implementation team members will not change and will be responsible for the accurate installation of all administrative, clinical and financial parameters for the Plan's program. | ||
| 5b | Development of an Implementation Action Plan, which is approved by the City that tracks key implementation deliverables. | ||
| 5c | Maintenance of an Issue Resolution and communication Log: Detailed implementation issue log that tracks issues, owners, and close dates. Offeror guarantees open issues will be closed prior to open enrollment. Offeror is responsible to define an issue resolution process that is acceptable to the City. | ||
| 6 | Claims: All Claims reimbursed or responded to within 10 business days. | Quarterly | Pass / Fail |
| 7 | Pricing Changes: Implementation of all pricing changes will be 100% accurate. | Quarterly | Pass / Fail |
| 8 | Financial Accuracy: At least 99.9% of claim payments made without error relative to total dollars paid. | Quarterly | ≥99.9% |
| 9 | Payment incident accuracy: Claim payment accuracy should be at least 98% as measured as the total number of claims with dollars paid correctly divided by the total number of paid claims audited in a statistically valid sample of claims for all members | Quarterly | ≥98% |
| 10 | Invoicing Errors: All invoicing errors will be credited back to City by the next billing cycle or Offeror will pay interest for each day late at the rate of 1.0% per month or, if lower, the highest interest rate permitted by law. | Monthly | ≥100% |
| 11 | Mail Order Turnaround Time: Average turnaround time within 2 business days for CLEAN mail order Rxs. Measured from date mail order request is received to date mail order is shipped. | Quarterly | Pass / Fail |
| 12 | Mail Order Turnaround Time: Average turnaround time within 4 business days for mail order Rxs requiring administrative/clinical intervention. Measured from date mail order request is received to date mail order is shipped. | Quarterly | Pass / Fail |
| 13 | Specialty Turnaround Time: Average turnaround time within 2 business days for CLEAN specialty Rxs. Measured from date mail order request is received to date mail order is distributed. | Quarterly | Pass / Fail |
| 14 | Specialty Turnaround Time: Average turnaround time within 4 business days for specialty Rxs requiring administrative/clinical intervention. Measured from date mail order request is received to date mail order is distributed. | Quarterly | Pass / Fail |
| 15 | Enrollment: At least 99% of enrollment eligibility and dependent data shall be updated within one (1) business day of receipt. Includes electronic file transfer and manual updates | Monthly | ≥99% |
| 16 | Eligibility File Data Reporting: Eligibility file error reporting on all eligibility file updates will be provided to the Plan <= 2 business days. | Monthly | Pass / Fail |
| 17 | Average Speed to Answer: All calls shall be answered within an average of 30 seconds (exclude IVR). | Quarterly | Pass / Fail |
| 18 | Abandonment Rate: Less than 2% of calls are abandoned | Quarterly | Pass / Fail |
| 19 | Telephone Inquiry Answer Time: At least 99% of telephone inquiries are responded to within 5 business days. | Quarterly | Pass / Fail |
| 20 | Telephone Issue Resolution: 99% of all telephone issues will be resolved on the first call. | Quarterly | Pass / Fail |
| 21 | Escalated Issue Resolution: Offeror will resolve member issues within 2 business days for any case that required the involvement of City staff due to incorrect or incomplete information being provided by the Offeror. | Quarterly | Pass / Fail |
| 22 | Survey – Member Satisfaction: Offeror will obtain at least a 90% satisfaction rate on the Annual member satisfaction survey conducted by the Offeror. | Annually | Pass / Fail |
| 23 | Account Management Responsiveness: All calls are returned by the account service representative within one (1) business day. | Quarterly | Pass / Fail |
| 24 | Survey – City of Tucson Benefit Team: Offeror guarantees a satisfaction rating of at least 90% on a scale from 0 – 100% based upon mutually agreed methodology. | Annually | ≥90% |
| 25 | Implementation Delivery Dates: Offeror will provide an Annual project plan and meet all mutually agreed upon plan delivery dates including staff training, transition of cases, systems programming, plan revisions, testing, and report development. | Annually | Pass / Fail |
| 26 | Group Structure and Benefit Plan Design: The group structure and benefit plan design will be entered into the claim adjudication system within 30 calendar days from receiving final sign-off from the City entities on the benefit plan design and summary documents and no later than 60 calendar days prior to the start date. An issue resolution process for open enrollment issues must be submitted and approved by City; issues must be resolved within three (3) business days and reported on a weekly Offeror log. | Monthly | Pass / Fail |
| 27 | Plan Authorizations: Offeror will implement all Plan Authorizations as directed and within specified time frames and provide documentation to support system set up, testing and appropriate member/provider communication as necessary. | Annually | Pass / Fail |
| 28 | Reporting: All monthly, quarterly, annual reports and data submissions shall reflect accurate data and be submitted by the Offeror and received by City in the timeframes agreed to during implementation. | Monthly | Pass / Fail |
| 29 | Delivery of Standard monthly Reports: Offeror will deliver its management reports to the City within 30 calendar days after the end of the month. | Monthly | Pass / Fail |
| 30 | Delivery of Standard quarterly Reports: Offeror will deliver its management reports to the City within 45 calendar days after the end of the quarter. | Quarterly | Pass / Fail |
| 31 | Delivery of Annual Management Reports: Offeror will deliver its management reports to the City within 60 calendar days after the end of the calendar year. | Annually | Pass / Fail |
| 32 | Reporting Accuracy: All submitted reports must be at least 98% accurate and must be HIPAA compliant. | Monthly | ≥98% |
| 33 | Point-of-Service System and Data Availability: Offeror will provide City of Tucson with a point-of-service system that can process claims and that permits City of Tucson access to the Offeror’s claim and data systems. Point-of Service availability measurement excludes telecommunication failures and system maintenance. | Monthly | ≥98.8% |
| 34 | Online Reporting Data Availability: Online reporting data will be available within an Annual average of fifteen (10) calendar days after the billing cycle that contains the last day of the month. | Monthly | Pass / Fail |
| 35 | Benefit Modeling Requests: | Quarterly | Pass / Fail |
| 35a | For standard benefit plan modeling (e.g., Copayments, Utilization Management, Network, Formulary) will be provided within 5 business days. | ||
| 35b | Requests for custom benefit plan modeling (e.g., Copayments, Utilization Management, Network, Formulary) will be provided within 10 business days. | ||
| 36 | Market Check: Offeror guarantees to proactively provide a market check following the initial 15 months of this Agreement and beginning on the second quarter of every subsequent contract year. | Every Months 15 | Pass / Fail |
| 37 | Retail Pharmacy Turnover: Less than 5% of the retail network pharmacies will leave the retail network. | Quarterly | Pass / Fail |
| 38 | Mail Order Dispensing Accuracy: At least 99.995% accuracy rate – reported errors or discovered errors (e.g., correct drug, correct strength, correct dosage form, correct label, correct participant name, correct participant address). | Quarterly | ≥99.995% |
| 39 | Pharmacy Audit Resolution: Response to audit findings after receipt of claim audit findings will be 30 days or less. | Quarterly | ≤30 days |
| 40 | Claim Detail Files: All claim detail extract files will be provided to external vendors and City within 8 calendar days of request or scheduled delivery date. | Quarterly | ≤8 days |
| 41 | High Cost Claimant: 100% of all members receiving a prescription with a plan cost ≥ $10,000 will have their medication reviewed by a pharmacist within seven (7) calendar days of claim adjudication and complete a member and / provider outreach to ensure the medication is prescribed appropriately and member understands how to use the medication and signs of an untoward event. | Monthly | Pass / Fail |
| 42 | Opioid Claimant: 100% of all members receiving an opioid prescription ≥ 50 MME and 8 days of therapy will have their opioid medication use reviewed by a pharmacist within thirty (30) calendar days of claim adjudication and complete an outreach. | Quarterly | Pass / Fail |
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