40DHHS-S3214-Scope-of-Work.docx

RFP 40DHHS-S3214 Pharmacy Benefits Manager Scope of Work

GOALS AND OBJECTIVES

The PBM will serve People Living with HIV/AIDS (PLWHA) eligible for ADAP/NMAP Coordination of benefits and pharmaceutical services include:

Retail point-of-sale.

Formulary management.

Medication management.

Coordination of Benefits with Medicare Part D.

Access to broad base of pharmacies throughout the State of Nevada; and Providing program medication, claims and client data to the State of Nevada Call Center management including technical and pharmacy prior authorization support.

Pharmacy claims processing (including development and maintenance of benefit rules and required reference files.) The Vendor is responsible for processing pharmacy claims.

Drug rebate Management for ADAP/NMAP, Federal, Supplemental (AIDS Crisis Task Force, contracted rates), 340B Rebates; and Reporting including but not limited to, Weekly Rebate Claims Detail Report by Paid date, Monthly & Quarterly Drug Rebate Report, Monthly Update Report, Quarterly Clinical Report.

The PBM will provide coordination of benefits and pharmaceutical services for the following three (3) groups under ADAP/NMAP:

Uninsured - Drug assistance for the uninsured (total ingredient cost);

Insured - Co-payment assistance (co-payment or coinsurance cost); and Medicare - Persons eligible for Medicare Part D (co-payment, co-insurance cost and donut hole coverage).

The PBM is expected to administer OoH/ADAP/NMAP’s Uninsured, Insured and Medicare components for members with seamless coordination of benefits. The PBM must provide access through an integrated retail service program with prompt claim handling and customer service capabilities.

All members enrolled with current PBM will rollover to the new PBM. All claims history must be converted into the new system. Prospective Vendors are to offer comprehensive PBM services including:

Claims Adjudication Coordination of Benefits with Medicare Part D Manage the data sharing agreement with Centers for Medicare & Medicaid Services (CMS) Network Pharmacy Management Formulary Management Medication Management Data Reporting Federal & Supplemental (ACTF) Rebate Management 340B Rebate Management

Submission and Reconciliation

The Vendor must provide at a minimum, transparent, and pass-through network pharmacy rates, competitive administrative fees, transparent drug rebate program, national pharmacy network, formulary management, specialty drug management, an online pricing tool that includes all network pharmacies and all formulary drugs, and utilization management services.

The Contract awarded through this RFP shall facilitate eligible ADAP/NMAP clients’ access to medication in an effective and efficient manner. Specifically, the Vendor shall:

Provide pharmacy benefits management services, including claims adjudication, coordination of benefits and point-of-sale processing services to eligible clients with coverage through Medicare Part D, private insurance, as well as those who are uninsured and receive medication benefits through ADAP/NMAP;

Conduct transactions with a comprehensive distribution network of pharmacies, including national retailers, local pharmacies, and specialty pharmacies.

Provide reporting that meets client-level data requirements of ADAP/NMAP and Health Resources and Services Administration (HRSA); and Eligibility determination services for all persons applying for ADAP/NMAP shall be performed by the vendor . The Vendor must have or be able to develop a mechanism for:

Electronically receive eligibility information and Provide data that matches the requirements of ADAP/NMAP and HRSA.

OoH shall retain authority for the development and management of the ADAP/NMAP Formulary.

Vendors will, at a minimum, duplicate the level of coverage presently offered to the members of the federally funded ADAP/NMAP. The current ADAP/NMAP Networks consists of approximately 300 pharmacies. However, this does not preclude the Vendors from presenting alternative solutions.

Vendors should be able to provide an interface or a means of being able to check Medicaid Eligibility prior to processing claims.

SCOPE OF WORK

This contract will be for a total of five (5) years, which includes one (1) year of implementation and transition planning with the current awarded pharmacy benefits manager.

The Scope of Work is broken down into tasks, activities, and deliverables. The task and activities within this section are not necessarily listed in the order that they shall be completed. Vendors shall reflect within their proposal and preliminary project plan their recommended approach to scheduling and accomplishing all tasks and activities identified within this RFP. The awarded Vendor shall provide the following services for this scope.

The awarded Vendor shall have at least ten (10) years’ experience providing pharmacy benefit management services. Vendor shall be familiar with the AIDS Crisis Task Force (ACTF) supplemental rebate prices and manufacturer contracted exclusions. Experience of at least seven (7) years and shall demonstrate within their proposal the ability to provide the following:

Shall administer the ADAP/NMAP Formulary Perform a retrospective review of current ADAP/NMAP client prescription claims and medical records, if available and agreed to by the party’s medical data, to evaluate the appropriateness of each current ADAP/NMAP client therapy based upon generally accepted current clinical pharmacy practices.

Ensure all groups of ADAP/NMAP (Uninsured, Insured, Medicare) have access to PBM services 24/7, 365 days a year.

Provide a web portal that allows access for members, providers, State staff, Vendor staff, and other external stakeholders.

A detailed, mapped recoupment process for instances where other prescription coverage has been identified, so that claims can be reversed and rebilled to other payers, such as, Medicaid and Medicare.

Coordinate coverage and benefits with insurance providers including Medicare Part D Prescription Drug Plans (PDP) and ensure that applicable expenditures are credited toward meeting clients’ TrOOP expenditure requirement. As part of this responsibility, the Vendor would participate in the electronic data exchange processes as specified by CMS for reporting client TrOOP expenses.

Oversee the payment of medication deductibles, coinsurance, co-payments, and costs of medications during any gaps in coverage for ADAP/NMAP clients enrolled in third party insurance, including Medicare Part D (PDP).

Coordinate and oversee the (a) billing of clients’ insurance and/or Medicare Part D Plan and (b) payment of the co-payment on behalf of insured clients (c) payment of the total ingredient cost for uninsured clients. ADAP/NMAP clients do not pay co-payments up front and then seek reimbursement from the Program; ADAP/NMAP is unable to directly reimburse clients for co-payments. The Vendor must therefore be capable of submitting payment on behalf of ADAP/NMAP clients and OoH will then reimburse the vender for those claims.

Ensure that ADAP/NMAP does not pay for medication(s) not on the ADAP/NMAP Formulary.

Ensure that procedures are in place that prevent a duplicate discount and/or avoid discriminatory practices, as outlined in the 2023 State of Nevada Assembly Bill 434 related to 340B drugs.

Maintain, for ADAP/NMAP, a unique Prescription Bank Identification Number (Rx BIN) and a unique Pharmacy Benefit Processor Control Number (PCN) to code for all ADAP/NMAP groups (Uninsured, Insured, Medicare).

Ensure network pharmacies resolve payment errors made to third party insurance and Medicare Part D (PDP) within 90 days.

Can transmit primary and/or secondary insurance information to the pharmacy.

Allow for coordination of primary, secondary, and tertiary payers of prescription claims. ADAP/ NMAP is considered to be the payer of last resort, and therefore, must always be billed as the final payer for prescription claims based on lesser-of-logic.

Provide remote access to the Vendor’s claim system to include:

Pharmacy locator Real-time claim tracking/history Medication formulary and pricing information Client benefit level information Client prescription history Prior Authorization

Annual Site Visit: Vendors must comply with the HRSA National Monitoring Standards for Ryan White Part Part B Grantees. Site visits will review program requirements, performance, and responsibilities in five (5) main areas:

Section A: Access to Care Section B: Eligibility Determination Section C: Anti-Kickback Statute Section D: Grantee Accountability Section E: Reporting Section F: Monitoring

Additional information on the requirements can be found at: https://targethiv.org/sites/default/files/media/documents/2024-02/DSCHP_2023_RSV_D1_RWHAP_Part_B_National_Monitoring_Standards_and_Manual.pdf

ADAP/NMAP: Claims Processing and Operational Support

The PBM must ensure claims processing policies and procedures are compliant with all applicable state and federal laws, regulations, rules, and policies. Claims adjudication is the responsibility of the PBM.

The Vendor must describe their approach for handling provider payments. In adjudicating claims the PBM would perform several prescribed functions, including applying Prior Authorizations and COB functions.

Pharmacy Point-of-Sale (POS)

The PBM Vendor will operate a real‐time Point-of-Sale (POS) online claims processing system, utilization management (UM), prior authorization, messaging, processing and 340B eligible drugs. Additionally, the Vendor must describe their approach to providing a POS system.

The PBM’s POS claims processing system must be capable of adding, changing, or removing adjudication rules, edits, and customized transmission messages to accommodate required changes for its current and future pharmacy programs.

The system should be capable of processing National Drug Code’s (NDC), inclusive of drug’s labeler, product(s) and package sizes.

The system must be capable of displaying the formulary status of a drug.

Coordination of Benefits (COB)

The PBM Vendor must validate claims to determine whether there is one or more liable third party that must be billed prior to billing ADAP/NMAP programs including, but not limited to, the following:

Denying payment for claims when a beneficiary is covered by one or more liable third party until the billing provider indicates the claim has been fully adjudicated (paid or denied) by the other payer(s).

Utilizing TPL data and eligibility records to ensure ADAP/NMAP is the payor of last resort.

Processing claims where multiple third parties are liable.

Overriding COB editing as specified by ADAP/NMAP.

Maintaining indicators to identify Medicare Part B drugs and process the claim balance remaining after subtracting the Medicare Part B payment for beneficiaries dually enrolled in Medicare and any of the ADAP/NMAP’s programs.

Maintaining indicators to identify Medicare Part D drugs and process the claim balance remaining after subtracting the Medicare Part D payment for beneficiaries dually enrolled in Medicare and any of the ADAP/NMAP’s programs.

Coordinating benefits automatically with all primary payers including capturing and storing the primary payer’s data; and Obtaining maximum cost avoidance and reimbursement for beneficiaries covered by other liable third parties.

Be able to identify if another 340B agency has attempted to claim the drug discount (i.e., program income) which could result in the ADAP/NMAP not being able to claim the 340B rebate and/or program income prior to invoicing to align ADAP/NMAP with Nevada State Statute.

Post Payment Claims Management

As requested by ADAP/NMAP, the PBM Vendor must process financial claims adjustments to pharmacy payments, such as corrective actions identified from post‐payment audit findings and other adjustments.

The Vendor must describe their approach to managing financial adjustments and reversals.

ADAP/NMAP: Pharmacy Network Management

The PBM Vendor is the first point of contact for providers with questions, concerns and complaints and must implement and maintain a provider contact and problem resolution tracking system.

The system must, at a minimum, document, and track contacts with providers, identify issues and describe problem resolution.

The PBM Vendor must review the data submitted by providers, obtain any corroborating information, and prepare an analysis of the issues. The analyses must be reviewed with ADAP/NMAP staff at regularly scheduled meetings.

The PBM Vendor is responsible for provider communications and must maintain current contact information for the provider networks.

Provider and Beneficiary Support Services

The PBM Vendor must implement a pharmacy and prescriber portal and provide support, updates, and maintenance customized to meet the needs of ADAP/NMAP.

The PBM Vendor must guarantee any data exchange on its website between the PBM Vendor and the ADAP/NMAP or providers will be secure.

The Vendor must describe their approach to providing a portal that supports effective communications with providers including, but not limited to, the following:

Providing outreach, training, and informing materials to Nevada ADAP/NMAP clients, providers and pharmacies.

Providing web-based services to support communication and tools for Nevada ADAP/NMAP.

Providing real-time data access, data feeds (at least daily), and support for the purposes of coordinating care across the delivery system with the ADAP/NMAPs’ other contracted partners.; and Working with the ADAP/NMAP and other contracted partners regarding continuity of care.

To ensure Nevada ADAP/NMAP are able to continue to meet their contractual obligations relating to Nevada ADAP/NMAP care coordination, medication adherence, and other related responsibilities, ADAP/NMAP will work directly with the Vendor to ensure that it meets all Nevada Medicaid requirements related to data feeds and real-time access into the Nevada Medicaid electronic portal/environment.

Pharmacy Call Center/Help Desk Services

Pharmacy Call Center Services will be accessible to providers to obtain answers to questions and get information on pharmacy claims via telephone, e‐mail, and the Web twenty‐four (24) hours a day, seven (7) days a week. Pharmacy Call Center Services include technology and/or services that provides:

Integration of call center technologies including access by authorized ADAP/NMAP users.

A tracking mechanism for call center results, volume, and efficiency.

Improvement of ADAP/NMAP communications.

Functionality to process prior authorizations.

Clinical key personnel to respond to all clinical questions and approval or denial of PA requests.

Search capabilities that speed access to needed information across the system through easy‐to‐use search and phonetic matching.

Integrated online help and training throughout the System.

Ability to provide answers and responses to inquiries on System processes and System troubleshooting from providers, pharmacies, ADAP/NMAP and Vendor users; and Application and Software support.

E-Prescribing and E-Prior Authorization Capabilities

ADAP/ NMAP is interested in promoting the electronic exchange of information to support administrative simplification.

Currently, pharmacy benefit eligibility verification, medication history and formulary information are made available to all Electronic Medical Record (EMR) systems statewide. This is accomplished through PBM’s existing infrastructure, and the network exchange services with Allscripts Healthcare Solutions, Inc. and SureScripts, LLC.

ADAP/NMAP wishes to work on moving to a PDL interface to assure accurate and meaningful displays of formulary and coverage limitations to prescribers at the time of prescribing.

In addition, the ADAP/NMAP wishes to expand these capabilities by providing the means to perform electronic prior authorizations through the EMR.

The Vendor must describe its approach to work with ADAP/ NMAP to meet the goals of ADAP/NMAP for electronic prescribing and electronic prior authorization and for providing prescribers and pharmacies information promoting both.

ADAP/NMAP: Pharmacy Benefit Management and Clinical Programs

Pharmacy Benefit Management services support the program in the following areas:

Drug benefit management services.

Drug utilization review.

Utilization management programs PDL management.

All these services must encompass drugs processed through both the pharmacy benefit and those physician‐administered drugs processed through the medical benefit.

The Vendor must describe their approach to providing the following PBM services to ADAP/NMAP.

Utilization Management Programs which encompass

Prior authorization, quantity limit, step therapy, and formulary.

Development and dissemination of clinical criteria, procedures for its application, and proper documentation of all clinical decisions.

First reconsideration review of denials by a clinical pharmacist when requested and access to independent physician reviewers; and Proper notification of all denials and approvals to members and prescribers within timelines established by applicable law and state policies.

Management of ADAP/NMAP Closed Formulary (NCF)

The formulary is a key feature in the ADAP/NMAP pharmacy best practices and cost control program and identifies drugs that are clinically safe and effective, and cost‐effective to the State.

Drugs are reviewed by a Drug utilization committee for clinical safety, efficacy, and evidence‐based guidelines for use.

Drugs are listed as “preferred” or “non‐preferred” based on thorough clinical and cost evaluations.

Vendors shall describe opportunities they can provide, leveraging clinical expertise in developing more aggressive and innovative formulary designs. Include your organization’s viewpoint and vision, opportunities, and/or abilities regarding the following:

Strategies to assess the evidence‐based value of high‐cost prescription drugs and any quality‐of‐life value the drugs may have, when considering drugs for formulary inclusion/exclusion.

Consideration during formulary development of long‐term medicals costs that may be the direct impact of adverse events associated with certain drugs.

Benefit designs that incorporate the use of more than one formulary to provide options to members based on cost share, covered vs. non‐covered drugs, or specialty vs non‐specialty formularies, etc.

Prescriber and member engagement strategies that align prescribing patterns and member behaviors with formulary design; and Tools utilized by your organization to measure the effectiveness of programs, designs, and concepts your organization implements.

Provide clinical recommendations and pharmacoeconomic analysis.

Provide designated clinical pharmacist support for assistance with program‐ specific policy development and implementation.

Provide a description of your organization’s rebate processing and rebate management. Does your organization perform contract negotiations for rebates? If so, what is that process? Does your organization provide invoicing on rebates?

Describe the relationships your organization has with prescription drug manufacturers and pharmacy benefit managers and the impact on our organization’s ability to negotiate and influence pricing, discounts, and rebates.

ADAP/ NMAP: Prior Authorization Program

An aggressive and effectively managed Prior Authorization (PA) program has been demonstrated to provide savings to ADAP/NMAP’s pharmacy program, while at the same time improving prescribing practices and overall quality of care.

ADAP/NMAP seeks modern, state-of-the-art prior authorization systems and capabilities.

These services must encompass drugs processed through both the pharmacy benefit and those physician‐administered drugs processed through the medical benefit.

The PA program must be capable of utilizing medical codes such as CPT, HCPCS, ICD‐9, and ICD‐10 codes to make PA determinations in an automated fashion through POS.

In addition, the PA process must accommodate the electronic submission of forms (via provider portals) to the provider call center(s) for manual PA determinations.

Both pharmacies and prescribers should have an electronic means to check on the status and expiration date of a PA through the provider portals.

Additionally, ADAP/NMAP is interested in detailed and ongoing analyses of program success focused on evaluation of drugs, criteria, return on investment, and recommendations for change.

Lastly, ADAP/NMAP is interested in implementing a PA process through the electronic medical records of provider practice management systems.

The Vendor must describe their approach for conducting Prior Authorizations now and in the future.

ADAP/NMAP: Support the State Appeal Process

In addition to the PA process, ADAP/NMAP seeks support of the appeal process for drugs whose coverage has been denied.

ADAP/NMAP receives several appeals for drugs either denied through the PA process or for non‐covered products.

The PBM Vendor must support the State’s appeal process, including, but not limited to:

Notifying providers and beneficiaries of their appeals rights in accordance with ADAP/NMAP’s policy.

Coordinating with State personnel who oversee the grievance and appeals process.

Preparing the appropriate reports and documents to support the PBM Vendor’s actions resulting in the request for an appeal from a beneficiary or provider.

Providing the services of a registered pharmacist to address an appeal related to pharmacy benefit services.

Providing resources to address appeals related to claims disputes; and Complying with the mandates and timelines stipulated by ADAP/NMAP.

ADAP/NMAP: Nevada Mediation Assistant Program Medical Advisory Committee (NMAP-MAC)

The vendor shall help re-establish and be responsible for a committee to provide Drug Utilization Review services and recommendations on behalf of ADAP/NMAP.

The committee shall consist of licensed physicians, pharmacists, and clinical staff.

The Bi- Laws in Attachment 4 are an example of Bi-laws that will need to be implemented and voted on by the committee.

All HRSA PCN’s that reference ADAP Medical Advisory Committees, Open Meeting laws, and State Statutes are to be followed for these meetings.

ADAP/NMAP: Reimbursement Formula

ADAP/NMAP currently reimburses all drugs and supplies under the following “lesser of” logic:

National Average Drug Acquisition Cost (NADAC) + Dispensing Fee Wholesale Acquisition Cost (WAC) + Dispensing Fee Federal Upper Limit (FUL) and Dispensing Fee Gross Amount Due (NCPDP field 430-DU) Usual and Customary (NCPDP field 425-DQ)

ADAP/NMAP: Medication Therapy Management:

Medication Therapy Management (MTM) is a partnership of the pharmacist, the beneficiary and other health professionals that promotes the safe and effective use of medications and helps beneficiaries achieve the targeted outcomes from medication therapy.

Nevada believes that any MTM program implemented must include the analytical, consultative, educational, and monitoring services provided by pharmacists to help beneficiaries get the best results from medications through enhancing understanding of medication therapy, increasing adherence to medications, controlling costs, and preventing drug complications, conflicts, and interactions.

ADAP/NMAP is interested in developing an MTM program that will comply with all Part D requirements for such programs, will be offered to both Medicaid and Medicaid/Medicare eligible populations, and will be integrated into and coordinate with other ADAP/NMAP initiatives.

This is envisioned as utilizing a combination of community pharmacists who currently see beneficiaries on a regular basis and supply their medication needs, and State and/or PBM Vendor clinical pharmacists who will coordinate with ADAP/NMAP, community pharmacists, and other stakeholders to assure continuity Pharmacists should be reviewing medication regimens for potential problems such as drug interactions, duplications of therapy, appropriate dosing, dosage forms, and routes of administration, medication adherence and compliance, side effects, cost optimization such as promoting generic utilization, and assuring compliance with ADAP/ NMAP’s Formulary.

The MTM program goals are:

Strive to reach optimum therapeutic outcomes for targeted beneficiaries through improved medication usage.

Reduce the risk of adverse events.

Be developed in cooperation with licensed and practicing pharmacists and physicians.

Be furnished by pharmacists or other authorized providers.

Distinguish between services in ambulatory and institutional settings; and Be coordinated with any care management plan established for a targeted individual.

ADAP/NMAP: Benefit Design and Consultative Support

The Vendor must describe its approach to providing benefit design and support, in particular the ease of implementing and making ongoing programmatic changes to the benefit program.

ADAP/NMAP is interested in understanding the Vendor’s:

Ability to implement, operationalize and manage ADAP/NMAP’s complex benefit designs with multiple funding sources and various eligibility requirements.

Flexibility in pharmacy reimbursement structures such as Average Acquisition Cost (AAC), National Drug Acquisition Cost (NADAC), Wholesale Acquisition Cost (WAC), and 340B pricing designs Ability to modify benefit plans in a timely and cost‐effective manner for ADAP/NMAP Ability for ADAP/NMAP staff to make changes to the benefit design and operational features, such as POS messaging.

Ability to ensure that the screens and menus are logical, intuitive to use, and support efficient workflow.

The Vendor should describe its ongoing approach to enhancing operational, program, and clinical value.

The Vendor should include the approach to identifying recommendations for program improvements, cost reduction/avoidance strategies, and operational efficiencies.

The Vendor shall Explain how these will be developed, how the Vendor will work with ADAP/NMAP to obtain necessary approvals and buy‐in, to implement changes, and measure and report on benefits realization on an ongoing basis.

ADAP/ NMAP: Management of Physician-Administered Drugs:

ADAP/NMAP would like to implement a more rigorous and structured approach to managing physician‐administered drugs, such as long acting injectables and infusions.

This could be achieved by integrating physician administered drugs into all aspects of the PBM Vendor’s utilization management programs such as applying quantity limits, step therapy, or clinical prior authorization criteria for such drugs.

ADAP/NMAP is also interested in innovative management models.

The Vendor should explain its utilization management strategies for managing Physician‐Administered drugs and indicate the extent to which they can currently, or could in the future, support ADAP/NMAP in improving the overall management of these drugs.

ADAP/NMAP: Reporting and Analytics

The PBM Vendor must provide reporting and analytic capabilities/services as described below that will support the reporting and analysis of claims data and PBM operations. Explain how the Vendor will provide the following:

Dashboard capabilities that support various roles of PBM operations and user‐ defined reporting views/screens based upon different roles, security profiles, etc. of various stakeholders.

Static or “canned” reports that are generated at predefined intervals and on demand by State users.

Parameterized reports that allow State users to select from a defined number of parameters that inform a report. Parameters should include, but not be limited to date or date range, beneficiary, beneficiary eligibility characteristic, program, drug, pharmacy, etc.).

Ad hoc querying and reporting capabilities

Services to define, create and run, as requested by the State, additional static, parameterized and ad hoc reports in a timely manner, as described in the above descriptions.

The reports must include, but are not limited to:

Utilization Reports Financial Reports Auditing Reports Rebate Forecasting Reports Preferred Drug List Reports Claims Processing Reports Coordination of Benefits (COB) Reports Net Cost Reports Monthly, quarterly, and annual reports that measure the performance of the PBM Vendor concerning contracted duties and responsibilities (e.g., KPM report) Federal and State‐mandated reports Trend reports Boards and Committee reports Call Center reports.

Clinical reports Business plans and project status Prospective and retrospective drug utilization review Ad Hoc reports and analyses

DAP/NMAP: Quality Assurance

Describe your organization’s quality assurance process to ensure accuracy of the drug file and the claims processing and ancillary systems proposed.

During the first and second cycles of claims, invoices and rebates, a thorough quality check will be completed with a PBM QA person and an ADAP/NMAP subject matter expert to ensure accuracy and expected results. The QA person should be available to come onsite to the OOH.

ADAP/NMAP: Management of State and CMS Drug Rebate Programs

ADAP/NMAP seeks full support of the Federal program. The Vendor should describe how it manages all aspects of rebate support including, but not limited to:

Producing Drug Rebate Invoices for drug manufacturers.

Providing rebate reporting to the State.

Reconciliation and resolving drug rebates disputes.

Supporting manufacturer inquires such as claims level detail.

ADAP/NMAP: Support of Supplemental Rebate (ACTF)

ADAP/ NMAP seeks full support of supplemental rebate processing ACTF.

The Vendor should describe how it will provide the following drug rebate procurement related services:

Have at least seven (7) years’ experience with the Aids Crisis Task Force (ACTF) rates and the manufacturer contracts associated to include (unit) exclusions where applicable.

Producing Drug Rebate Invoices for drug manufacturers.

Providing rebate reporting to the State.

Reconciliation and resolving drug rebates disputes.

Supporting manufacturer inquires such as claims level detail.

ADAP/NMAP: 340B Program Management

ADAP/NMAP utilizes the Health Resources and Services Administration’s (HRSA’s) Medicaid Exclusion File to identify 340B providers.

The Vendor must establish and maintain claims processing capability to appropriately process and pay claims from 340B providers as outlined by ADAP/NMAP Policy.

Per current policy, providers are not allowed to bill ADAP/NMAP for 340B stock.

The Vendor must describe their approach to supporting ADAP/NMAP in operating the program including, but not limited to

Administrative support Financial analysis Interacting with covered entities Invoicing Cost analysis And other tasks as directed by ADAP/NMAP.

The Vendor must be able to track all 340B claims to ensure that there are no duplicate discounts associated with the rebate prior to reimbursing ADAP/NMAP for the rebates associated with all 340B.

ADAP/NMAP: Culturally Competent Delivery of ADAP/ NMAP PBM Program Services

ADAP/ NMAP expects that the Vendor shall participate in the State’s efforts to promote the delivery of services in a culturally competent manner to all enrollees, including those with Limited English Proficiency, disabilities and diverse cultural and ethnic backgrounds regardless of an enrollee's and their supporter’s age, race, national origin, color, sex, sexual orientation, religious beliefs, veteran status, pregnancy, physical or mental disability, genetic testing, gender expression, or gender identity.

This includes the Contractor emphasizing the importance of network providers to have the capabilities to ensure physical access, accommodations, and accessible equipment for the furnishing of services to enrollees with physical or mental disabilities.

APPLICABLE REGULATIONS GOVERNING PROCUREMENT

RYAN WHITE PART B ADAP/NMAP POPULATIONS

The State will pay administrative fees and reimburse the PBM for the cost of prescription drugs after member(s) co=payment (if any) and discounts.

RYAN WHITE PART B ADAP/NMAP ENROLLMENT/ELIGIBILITY

Current Three-year Average Annual Utilization by Client Type as of September 2024:

Vendor will provide ADAP/NMAP & Medicaid eligibility determination. The vendor should describe how they would incorporate member eligibility determination into their scope of work to reduce the administrative burden on the State. ADAP/NMAP Eligibility is based on the following criteria: positive diagnosis of HIV, income at or below 400% of the FPL, and reside in Nevada Vendor must provide a PBM supported portal which is utilized for enrollment of ADAP/NMAP clients to include eligibility timeframes and insurance types to include the following requirements:

Searching for existing consumers using DOB, SSN#, URN#, first name, last name, etc.

Being able to determine which line item or eligibility span is active vs. not active.

Being able to view a consumer’s information without having to edit.

Ability to unlock records.

Having a notes section and being able to view notes without editing record.

Auto updates based on Medicaid files received. If consumer has active Medicaid, NMAP eligibility dates are automatically inactivated.

Being able to request a physical card mailed.

Being able to print and view a copy of the current and future pharmacy card.

Being able to future date an upcoming enrollment change when going from uninsured to insured.

Making sure that the “insured section” are mapping correctly to the correct payer source.

Access to claims data to confirm and tell consumer if PBM is being used or not used by pharmacy.

CURRENT ASSOCIATED PUBLIC BOARDS

SILVER STATES SCRIPT BOARD

Senate Bill 378 during the 2019 Legislative Session, established the Silver State Scripts Board (SSSB), previously known as the Nevada Medicaid Pharmacy and Therapeutics Committee, charged with developing the Nevada Medicaid Preferred Drug List (PDL.) ADAP/NMAP has utilized the SSSB to meet all the needs required by HRSA and Federal funding requirements.

CURRENT COMPUTING ENVIRONMENT

The current OoH ADAP/NMAP PBM is comprised of, but not limited to the following services:

Retail point-of-sale.

Formulary management.

Medication management.

Coordination of Benefits with Medicare Part D.

Access to broad base pharmacies throughout the State of Nevada.

Providing program medication and client data to the State of Nevada.

The PBM will provide coordination of benefits and pharmaceutical services for the following three (3) groups under ADAP/NMAP.

Uninsured-Drug assistance for the uninsured (total ingredient cost) Insured-Co-payment assistance (co-payment or coinsurance cost) and;

State Pharmaceutical Assistance Program for Medicare Part D- Personas eligible for Medicare Part D (co-payment or coinsurance cost)

The current ADAP/NMAP PBM provides a TPL check against Medicaid Eligibility because they do business with this state department also, however, in the case where our Medicaid and Office of HIV have different PBMs, an interface file will be need to be implement for the purpose of ensuring clients that are eligible for ADAP and not also eligible for Medicaid since ADAP is the payor of last resort. Also, a claims data file will need to be provided in csv format for the purpose of importing drug payments and insurance services into our CAREWare client level database as well as be able to have data integrated with CAREWare client level database and RWISE systems.

Call Center management including technical and pharmacy prior authorization support;

Pharmacy claims processing (including development and maintenance of benefit rules and required reference files). The Vendor is responsible for processing pharmacy claims.

Drug Rebate Management for ADAP/NMAP, Federal, Supplemental, 340BRebates; and Reporting including but not limited to Quarterly Drug Rebate Report, Monthly Update Report, Quarterly Clinical Report.

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