41NHA-S3992 - PEBP - Attachment 4.6.2. - Technical Proposal Questions.docx

Joe Lombardo Governor

NEVADA HEALTH AUTHORITY

NEVADA MEDICAID

4070 Silver Sage Drive Carson City, Nevada 89701

NVHA.NV.GOV

Stacie Weeks, Director

Ann Jensen, Administrator

Attachment 4.6.2 – Technical Proposal Questions This Request for Proposal (RFP) attachment outlines the Technical Proposal Questions that Contractors must answer in their Technical Proposal responding to this Solicitation. Contractors will be evaluated on the quality and completeness of their responses to the questions, and responses should demonstrate the Contractor’s full understanding of all contractual requirements contained in the Scope of Work.

The Contractor must provide a response to each question in this attachment. As prompted by the question, Contractors are expected to discuss their:

1. Approach to addressing the issue in the narrative question, highlighting how their approach will (a) allow the Contractor to fulfill the contractual requirements, (b) align with outlined program goals, and (c) represent innovation and/or best practices;

1. Capabilities to implement their proposed approach, which could include organizational structure, staffing resources, operational infrastructure, intended approach to engaging subcontractors, established operational protocols, and technology infrastructure and resources (e.g., IT systems and system capabilities); and

1. Experience related to the issue in the narrative question that illustrates how the Contractor has successfully addressed this issue in contexts comparable to those required of the PEBP pharmacy benefit manager (PBM) in Nevada.

Contractors should not assume that the individuals involved in the evaluation process are familiar with any current or past work activities with the State or in other states. Responses to each question should be complete and may not reference responses provided to other questions in the Technical Proposal.

When citing relevant experience, the Contractor must clearly state what program(s), state(s), and year(s) the experience comes from and how it will translate to the provision of PBM services for PEBP and to the issues discussed in the question. In responding to a question, if the Contractor will use a subcontractor to fulfill any part of the response, the Contractor must provide the name of the subcontractor and explain how the subcontractor’s performance will be no less effective than if done by the Contractor.

When providing data in a response, Contractors must include a brief description of each data measure, why it is a relevant measure of impact for the example provided, and a brief explanation of the data methodology (including sample size, where appropriate).

Contractors must adhere to the prescribed formatting requirements and guidelines outlined in Section 9 of the RFP. All materials must be prepared using 12-point Times New Roman font, single spacing, and one-inch margins on all sides. Pages must be numbered consecutively and require headers detailing the solicitation number, Contractor name, and attachment title applied consistently throughout the document. All submissions shall be provided in searchable, text-based PDF format, and scanned or image-only documents are prohibited. Contractors must label each section of their response in accordance with the exact question numbers or titles provided in the solicitation, and the use of unusual fonts, colored text, decorative elements, or embedded multimedia content is not permitted. Contractors are strongly encouraged to adhere to the recommended question-specific response lengths included in this attachment. The evaluation committee will not consider or score any pages submitted beyond the stated page limit for any given question. The question page limits, scoring weighting, and maximum number of points available are outlined in the table below.

Technical Proposal Question Scoring:

Technical Proposal Questions Operational Capabilities, Client Service, and Governance

Responses must include:

· A description of the account team structure, including roles, locations, dedicated capacity, and executive accountability for the comparable employer.

· At least two (2) examples in which you identified or escalated a service, financial, clinical, or implementation issue. For each example, please include: time to resolution, client communication approach, root cause analysis, corrective actions taken, and sustained outcomes.

· Examples of the governance calendar and performance dashboard used to service the comparable employer.

Responses must include at least three (3) examples of successful vendor integrations for the comparable employer. External vendors may include eligibility, medical, specialty, accumulator, navigation, utilization management, transparency, or member advocacy vendors. For each example, please provide:

· Integration approach

· Acceptance testing methodology

· Responsibility matrix

· Implementation challenges and resolutions

· Measurable results and outcomes

Implementation & Transition

· Implementation timeline with specific milestones, responsibilities, and readiness criteria

· Governance structure and cadence

· Conversion and testing approach

· Transition plan for eligibility, accumulators, active prior authorizations, refill history, and specialty patients

· Third-party and vendor coordination strategy

· Risk assessment and corresponding mitigation actions

· Member disruption assessment

· Lessons learned from the comparable case study

· Post-go-live support model and duration

Formulary & Clinical Management

· A recent formulary, biosimilar, GLP-1, specialty, new-to-market, utilization-management, or coverage exception decision. Describe the clinical rationale, financial considerations, client approval process, member impact, communications, and measured results.

· Governance controls separating clinical review and coverage decisions from manufacturer contracting, rebate considerations, affiliated pharmacy interests, and other financial incentives.

· Ability to approve, reject, or customize formulary changes, exclusions, utilization management criteria, continuation-of-therapy/grandfathering rules, prior authorization criteria, and exception processes; identify limitations, required lead times, and incremental fees.

· Standard notice periods and plan/member impact analyses provided before material formulary, utilization management, or coverage changes.

· Prior year performance for prior authorization, exceptions, and appeals, including turnaround times, approval/denial/appeal and overturn rates, compliance trends, and service level performance.

· A description of all affiliates, subcontractors, or other entities involved in utilization management, clinical review, appeals, or external review, including their roles, compensation, oversight, and conflict of interest controls.

· A demonstration of measurable clinical, financial, or access results.

· Your approach to specialty pharmacy choice, site-of-care management, limited distribution products, and coordination with the medical carrier.

· Your strategy for high-cost one-time therapies, including coverage review, outcomes tracking, payment risk mitigation, and member support; please address any ownership interests, preferred channels, financial incentives, limitations, or additional fees associated with the proposed specialty model.

Financial Operations

Provide at least two (2) examples from the last three years, preferably involving a public-sector, self-insured, or similarly complex employer. For each example, describe:

· The employer’s transparency objectives and the financial arrangements subject to review (e.g., retail, mail, specialty, rebates, GPOs/aggregators, copay assistance, affiliated entities, networks, and subcontractors).

· Information, reporting, and supporting documentation made available to the employer, including claim level data, rebate support, pricing inputs, pharmacy reimbursement information, acquisition cost support where applicable, and funds flow documentation.

· The employer’s audit and reconciliation rights, including any identified discrepancies and how discrepancies were corrected.

· How the Contractor disclosed and managed actual or potential conflicts associated with affiliated pharmacies, GPOs, rebate aggregators, preferred channels, or other related entities.

· Lessons learned and process improvements implemented as a result.

Separately, identify the standard and non-standard financial reporting, reconciliation support, data access, and audit support that would be available to NVHA during the contract term, including any limitations, incremental fees, or information that cannot be disclosed.

· Program scope and eligibility workflow by channel (Retail, Mail, Specialty).

· Claims adjudication handling, including accumulator/maximizer logic and member cost-share treatment.

· All compensation sources related to these programs, including direct/indirect payments, retained amounts, affiliate/subcontractor revenue, and other remuneration.

· All client/member fees, including whether they are included in base administrative pricing or separately charged.

· Operational, legal, or plan design limitations affecting program availability or administration.

· How Contractor will identify network gaps and access barriers.

· Any pharmacy types, regions, or member populations most likely to experience access challenges.

· Proposed strategies to address gaps, including network recruitment, contracting, and utilization management considerations.

· How Contractor will monitor network adequacy and access over time.

· Any operational, pricing, or implementation limitations associated with the proposed access strategy.

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