41NHA-S3992 - PEBP Scope of Work.docx

Nevada Public Employees’ Benefits Program (PEBP) Pharmacy Benefit Manager

Pursuant to 41NHA-S3992

Joseph Lombardo Governor State of Nevada

Stacie Weeks, JD MPH Director Nevada Health Authority

Table of Contents

1. General Expectations & Qualifications

1.1. General Contract Requirements

1.1.1. Contractor shall provide Pharmacy Benefit Manager (PBM) services for the Nevada Public Employees’ Benefits Program (PEBP). Contractor shall perform all functions necessary to administer the prescription drug benefit, including claims adjudication, formulary development and maintenance, pharmacy network management, rebate negotiation and administration, and utilization management tools designed to control costs and optimize clinical outcomes for PEBP members. PEBP administers comprehensive medical, prescription drug, dental, vision, life, and long‑term disability benefits for approximately 72,000 covered lives, and the PBM services provided under this Agreement shall fully support the program’s benefit structures, including the Consumer Driven Health Plan and available HMO offerings.

1.1.2. Should either party elect to terminate the agreement, in the event the termination results in a partial plan year, all rebate and pricing guarantees shall be honored without penalty and calculated pro-rata for the claims processed during the period the plan was in force.

1.1.3. The Contractor's administrative fee for run-out services will not exceed the core administrative fee in effect during the contract year of termination. No additional surcharges or transition fees will be applied to run-out processing.

1.1.4. The Contractor shall provide the NVHA with access to all historical claims, eligibility, and financial data, as well as reporting platforms and analytical tools, for at least twelve (12) months post-termination at no additional cost. Access must remain functional, auditable, and exportable to ensure continuity of oversight.

1.1.5. The Contractor confirms that, following receipt or issuance of a notice of termination, it will continue to administer the NVHA’s pharmacy benefit program using the same pricing, financial guarantees, service levels, clinical programs, network access, staffing, reporting, and contractual commitments that were in effect immediately prior to the notice of termination. Contractor further confirms that no degradation in service, operational support, or contractual performance will occur during the transition period.

1.1.6. The Contractor confirms that NVHA’s audit, security assessment, data-access, records-retention, legal-hold, incident-response, privacy, rebate reconciliation, pricing reconciliation, financial reporting, and other rights and obligations that by their nature extend beyond termination shall survive termination or expiration of the Contract for the period required by applicable law, this Agreement, or until the applicable obligation has been satisfied.

1.1.7. The Contractor confirms that it will not enforce any contractual provision, intellectual property claim, proprietary system restriction, data ownership claim, or other limitation that would delay, impair, or interfere with the NVHA’s implementation of a successor PBM or the continued administration of pharmacy benefits following termination of the Contract.

1.1.8. The Contractor shall allow the NVHA, or a designated third-party, to conduct annual market check assessments, otherwise known as "Market Checks" after the first year of the Contract term to determine the continued competitiveness of pricing and associated financial guarantees. Contractor will participate in annual Market Checks, as requested.

1.1.9. If the savings from an annual Market Check is greater than 0.5% percent (0.5%), the Contractor shall implement the full savings improvement identified by the Market Check within 30 days of NVHA approval.

1.1.10. During the Market Check process, the Contractor will not introduce new or modified contractual language unless requested by the NVHA.

1.2. General Financial Requirements

1.2.1. The Contractor confirms that all outstanding financial reconciliations, including but not limited to rebate reconciliations, pricing guarantee reconciliations, Key Performance Measures, audit findings, manufacturer-derived compensation, implementation credits, and any other financial obligations, will be completed and paid within ninety (90) days following completion of all applicable run-out claims processing unless otherwise mutually agreed.

1.2.2. The Contractor agrees that any pricing improvements resulting from a Market Check will not be offset by reductions in other financial guarantees, increases in administrative fees, the introduction of new fees, changes to rebate guarantees, or modifications to pricing methodologies unless expressly requested and approved by the NVHA.

1.2.3. The Contractor agrees that, as part of any Market Check, it will not exclude claim types, dispensing channels, drug categories, pharmacy types, or other populations from existing financial guarantees unless expressly requested and approved by the NVHA.

1.2.4. The Contractor agrees that all existing contractual definitions, financial reconciliation methodologies, Key Performance Measures, audit rights, reporting obligations, and other contractual protections will remain unchanged as part of any Market Check unless expressly requested by the NVHA.

1.2.5. The Contractor shall not require the NVHA to purchase optional products, proprietary programs, consulting services, specialty programs, clinical programs, data services, network products, or other fee-based offerings as a condition of receiving the pricing, guarantees, rebates, networks, or other terms proposed in this RFP, unless specifically identified in Contractor’s response and accepted by the NVHA.

1.2.6. The Contractor shall absorb all costs required to configure, maintain, update, and operate Contractor systems and integrations necessary to support NVHA requirements under this Agreement, including benefit design changes, utilization management changes, reporting changes, interface/API updates, and integration with NVHA-designated third-party systems. Such costs are included in Contractor’s administrative fees unless expressly identified in the Ancillary Fee Schedule.

1.3. PBM Service Scope

1.3.1. The Contractor confirms that all pharmacy claims data, rebate data, pricing data, formulary data, utilization management records, prior authorization records, eligibility data, reporting, analytics, and all derivative work products generated in connection with the NVHA's pharmacy benefit program are and shall remain the exclusive property of the NVHA. Contractor further confirms that such information will be provided to the NVHA or its designated representative in a mutually agreed electronic format at any time during or following the Contract term without additional fees or restrictions.

1.3.2. The Contractor must have at least 5 years of experience providing pharmacy management services for a state employee program.

1.3.3. The Contractor shall implement routine operational configuration changes requested by the NVHA, including eligibility, benefit configuration, routine communications, routine file exchanges, routine vendor integrations, and operational processes, within mutually agreed implementation timeframes and at no additional cost unless specifically identified in the Admin and Additional Fees tab in the Cost Proposal Workbook. Contractor shall identify any categories of operational changes that require additional fees, lead time, testing, or third-party coordination.

1.3.4. The Contractor shall assume fiduciary responsibility for all claims and appeal decisions (urgent, first level and second level).

1.3.5. The Contractor must be a current National Council for Prescription Drug Program (NCPDP) Member and maintain membership throughout the life of the contract.

1.3.6. The Contractor's Solution must adhere to, and be compliant with, current and future NCPDP standards.

1.3.7. The Contractor shall ingest, load, and utilize Member eligibility files at a frequency designated by the NVHA, and shall process ad-hoc eligibility files upon request. Updated eligibility files must be fully deployed into the Contractor's active production environment as soon as commercially practicable, but under no circumstances later than twenty-four (24) hours following receipt from NVHA or its designee.

1.3.8. The Contractor shall issue at least 99% of new Member ID cards within four business days and 100% within seven business days after receipt and processing of a processable eligibility record.

1.3.9. The Contractor must be responsible for onboarding and training current and future staff and will be responsible for maintaining a proper staffing ratio.

1.3.10. The Contractor must develop and provide an internal quality control program to ensure fulfillment of all activities assigned to the Contractor by the State.

1.3.11. The Contractor shall comply with NVHA requests for documentation, communication, and understanding of all projects in a timely manner and ensure quality control of all programs the Contractor manages. The Contractor shall provide real-time access to NVHA to the Contractor’s policy and procedure documents and all related business and clinical plans.

1.3.12. The Contractor shall strictly comply with all NVHA directives to remediate performance or alter operations, including the submission of the following documents, the format and contents of which shall be exclusively directed and approved by NVHA:

a. Change Control Memoranda (CCM): Written operational or system modifications, which require prior NVHA approval before implementation.

b. Corrective Action Plans (CAPs): Time-bound remediation plans to fix contract non-compliance, which must be submitted within 5 business days of an NVHA request.

1.4. Conflict of Interest & Fee Disclosure

1.4.1. The Contractor shall disclose all relationships that may present a conflict of interest, including any common ownership, shared management, share director membership, or affiliation with MCOs, pharmacies, PSAOs, wholesalers, or third-party entities.

1.4.2. The Contractor shall disclose to NVHA all direct and indirect fees, charges, or assessments imposed on pharmacies or third parties, including those affiliated through ownership, management, shared boards, or shared oversight.

1.4.3. The Contractor shall disclose to NVHA all sources of payment related to prescription drugs, including administrative fees, service fees, data-related fees, or any other remuneration received from manufacturers or third parties.

2. Account Management & Governance

2.1. Key Personnel

2.1.1. The Contractor shall maintain a dedicated account management team appropriate for the size and complexity of NVHA's pharmacy benefit program. Contractor will consult with NVHA before replacing key account personnel, except in circumstances outside the Contractor's reasonable control. At NVHA's request, the Contractor will replace key account personnel whose performance materially and adversely affects service delivery. Replacement personnel shall possess substantially equivalent qualifications and experience.

2.1.2. The Staffing Plan must include an organizational chart showing management structure and responsibilities for all operational areas.

2.1.3. The Staffing Plan must list Key Personnel with names, job titles, brief descriptions, qualifications, office locations, full-time equivalents (FTEs), and a description of how staffing levels will ensure consistent service delivery.

2.1.4. The Contractor shall assign a dedicated account management team for NVHA that includes, at a minimum, the following Key Personnel:

a. Account Executive. Senior relationship owner responsible for overall contract performance, executive escalation, and coordination of cross-functional Contractor resources.

b. Program Manager. Primary day-to-day point of contact between NVHA and the Contractor, responsible for coordinating communications, deliverables, and progress across clinical, operational, financial, and service activities, with decision-making authority for ongoing operational matters.

c. Clinical Lead (licensed pharmacist) or Clinical Account Manager. Responsible for clinical strategy and oversight, including formulary management, utilization management (including PA criteria), and clinical program recommendations and implementation support.

d. Operations/Implementation Lead. Responsible for implementation planning, solution configuration, testing coordination, operational readiness, and transition from implementation to steady-state operations, including oversight of approved change requests.

e. IT/Integration Lead. Designated technical point of contact responsible for systems and data integration, including eligibility/data file exchanges, interface/API coordination, testing support, and technical issue resolution.

f. Rebate and Manufacturer Economics Lead. Responsible for rebate and manufacturer economics administration support, including reconciliation coordination, reporting support, discrepancy resolution, and financial validation support.

g. Data and Reporting Lead. Responsible for delivery and quality of contractual, regulatory, and ad hoc reporting, including report development, documentation, and data integrity support.

h. FWA/Compliance Lead. Responsible for fraud, waste, and abuse (FWA) and compliance coordination related to NVHA’s pharmacy benefit program.

i. Executive Sponsor. Senior executive responsible for strategic oversight, issue escalation support, and ensuring Contractor organizational alignment and accountability to NVHA.

j. Information Security/Privacy Lead. Designated point of contact responsible for coordinating information security, privacy, security assessment, incident response, vulnerability remediation, and other security-related obligations applicable to NVHA. This role may be fulfilled by an appropriately qualified shared Contractor resource and is not required to be dedicated exclusively to NVHA.

2.1.5. The NVHA reserves the right to reject any Contractor staff assigned to the contract.

2.1.6. The Contractor shall identify each proposed team Member, role, responsibilities, years of experience, and anticipated level of involvement supporting the NVHA.

2.2. Key Personnel Qualifications

2.2.1. The Contractor and subcontractor personnel performing services under this Agreement must be located and perform such services within the United States. NVHA data, including PHI, PII, and other confidential or sensitive information, must not be accessed, processed, transmitted, stored, or supported from outside the United States without prior written approval from NVHA. Any approved exception remains subject to all applicable privacy, security, contractual, and Section 14 requirements.

2.2.2. The Contractor shall provide full-time key personnel dedicated to the contract and submit their names, positions, and contact information to the NVHA within sixty (60) days of contract award.

2.2.3. Key personnel shall be available during the NVHA’s working hours (8:00 a.m. to 5:00 p.m. PT, Monday through Friday), and at least one key personnel shall be available 24/7 as required by the NVHA.

2.2.4. Key personnel shall be available for onsite management or working sessions in Carson City, Nevada upon request by the NVHA.

2.2.5. The Contractor shall hire and train key personnel at least sixty (60) days before the solution's implementation, vacancy, or earlier if needed.

2.2.6. Substitution or reassignment of key personnel requires prior written approval from the NVHA, and the Contractor shall notify the agency within two business days of any resignation. Within 10 business days, the Contractor shall provide a detailed plan specifying how work is to be completed until replacement staff is hired.

2.2.7. The Contractor must outline a quality management plan that includes ongoing training programs for all staff to ensure compliance with state and federal regulations, procedures for monitoring staff performance and addressing any deficiencies in service delivery and a plan for regular evaluation and updates to the staffing plan based on program needs and regulatory changes.

2.2.8. The Contractor shall ensure that personnel with access to State systems or data are appropriately vetted, authorized, and trained. Personnel shall complete background screening or other suitability determinations appropriate to their responsibilities and level of access and shall acknowledge applicable security, privacy, and confidentiality obligations before access is granted.

2.2.9. The Contractor shall provide security awareness and role-based training and shall maintain records of screening, access authorization, confidentiality acknowledgments, and training completion. Access shall be promptly revoked or modified following termination, reassignment, or loss of business need.

2.3. Account Governance

2.3.1. The Contractor shall conduct regularly scheduled governance meetings, including operational reviews at least quarterly, strategic business reviews at least quarterly, and executive business reviews at least annually. Appropriate operational, clinical, financial, and executive representatives shall participate based on the meeting agenda. Meetings shall address financial performance, service levels, clinical initiatives, market developments, implementation activities, outstanding action items, and strategic recommendations.

2.3.2. The Contractor shall proactively identify and present cost-management and clinical improvement opportunities throughout the Contract term, including recommendations related to formulary strategy, biosimilars, specialty pharmacy management, utilization management, network optimization, manufacturer programs, and emerging market trends. Recommendations shall include estimated financial impact, implementation considerations, and associated risks.

2.3.3. The Contractor shall maintain documented service standards governing responsiveness, issue resolution, escalation procedures, and delivery of requested reports, analyses, and other NVHA deliverables.

2.3.4. The Contractor shall maintain an open-issue log and provide it to NVHA at least monthly. Contractor shall also make the account team available for weekly status meetings upon request from NVHA to review open issues and their status.

2.3.5. The Contractor account team shall respond to NVHA requests within two business days, and, when modeling is requested, provide a response or requested turnaround estimate within that timeframe.

2.3.6. The Contractor shall maintain a documented escalation matrix identifying operational, executive, clinical, and emergency contacts, expected response times, and escalation procedures. The matrix must include twenty-four (24) hour contact information for incidents or events requiring immediate response under this Agreement.

2.3.7. The Contractor shall maintain continuity of the assigned account management team throughout the Contract term and promptly notify NVHA of proposed staffing changes. Replacement personnel shall possess substantially equivalent qualifications and experience.

2.3.8. The Contractor shall annually present NVHA with a strategic pharmacy roadmap identifying emerging clinical programs, manufacturer contracting opportunities, biosimilar strategies, specialty pharmacy initiatives, digital innovations, regulatory developments, and other market trends that may improve clinical outcomes or reduce total pharmacy benefit costs. Recommendations shall include estimated financial and clinical impact, implementation considerations, and associated risks.

2.3.9. The Contractor shall provide NVHA with direct access, at no additional cost, to subject matter experts, including clinical strategy, specialty pharmacy, manufacturer contracting, formulary management, rebate strategy, pharmacy operations, data analytics, technology, legal/compliance, and financial management resources, as reasonably requested throughout the Contract term.

2.3.10. The Contractor shall develop and maintain an annual governance calendar identifying operational reviews, strategic planning sessions, executive business reviews, implementation milestones, reporting reviews, contractual performance reviews, and other recurring governance activities.

2.3.11. The Contractor shall prepare governance meeting agendas in advance, document meeting minutes, action items, responsible parties, and target completion dates, and distribute meeting materials to NVHA following each governance meeting.

2.3.12. The Contractor shall utilize the documented escalation process to promptly escalate unresolved operational, clinical, financial, contractual, or implementation issues until resolution is achieved and will provide NVHA with regular status updates throughout the escalation process.

2.3.13. The Contractor shall conduct an annual innovation review highlighting emerging pharmacy management capabilities, digital tools, manufacturer programs, specialty pharmacy innovations, and other opportunities relevant to NVHA.

2.3.14. The Contractor shall annually review contractual commitments, governance responsibilities, reporting obligations, and key deliverables with NVHA to ensure ongoing compliance and alignment with Contract requirements.

2.3.15. The Contractor shall maintain a documented issue-triggered escalation protocol for high-risk Member and claim events. At a minimum, the protocol must include escalation triggers, response timelines, accountable owners, and required status updates to NVHA for: (i) any single drug claim with gross cost exceeding $5,000 (or other NVHA-defined threshold), (ii) repeat Member contacts regarding the same unresolved issue, (iii) access-to-medication disruptions, and (iv) other NVHA-designated priority events. Contractor shall identify root cause, interim mitigation, and final corrective action for each escalated event.

2.3.16. The Contractor shall notify NVHA immediately of any issue reasonably expected to require state or regulator notification, and shall support NVHA in preparing required communications, documentation, and corrective action plans. The Contractor shall not provide regulator-facing communications related to NVHA’s program without prior NVHA review and approval, except where legally required on an emergency basis, in which case Contractor shall notify NVHA as soon as practicable and provide all submitted materials.

2.3.17. The Contractor shall maintain planned and unplanned outage management procedures for all systems, tools, and services supporting NVHA. Contractor shall provide immediate notice of any outage affecting claims adjudication, Member services, reporting access, clinical operations, or file/data exchange. For planned outages, the Contractor shall provide advance notice, expected duration, business impact, and mitigation/continuity steps. For all material outages (i.e., outages lasting 60 minutes or longer), the Contractor shall provide escalation contacts, regular status updates through resolution, root cause analysis, corrective action plan, and post-incident validation results, including any required reprocessing or remediation activities. Where an outage or service disruption results from, involves, or reasonably indicates a security incident, the Contractor must also comply with the security incident notification, investigation, evidence preservation, and response requirements of Section 14.

2.3.18. The Contractor shall proactively notify the NVHA of legislative, regulatory, industry, or market developments that may affect the NVHA's pharmacy benefit and provide recommendations regarding operational, financial, contractual, or clinical impacts.

2.3.19. The Contractor shall provide implementation and ongoing operational support necessary to implement legislative, regulatory, or industry changes affecting the NVHA's pharmacy benefit.

2.3.20. NVHA-designated staff shall complete an annual evaluation of the Contractor using a survey and methodology approved by the NVHA.

3. Transparency & Compensation Disclosure

3.1. The Contractor confirms each major PBM service component may be priced, contracted, and administered independently without reliance upon other PBM service components.

3.2. The Contractor confirms proposed pricing is not dependent upon the NVHA awarding all PBM services to a single vendor.

3.3. The Contractor confirms the NVHA may carve out Specialty Pharmacy services without triggering repricing of remaining PBM services.

3.4. The Contractor confirms the NVHA may carve out Mail Pharmacy services without triggering repricing of remaining PBM services.

3.5. The Contractor confirms the NVHA may carve out Utilization Management or Clinical Management services without triggering repricing of remaining PBM services.

3.6. The Contractor confirms the NVHA may carve out Rebate Administration services without triggering repricing of remaining PBM services.

3.7. The Contractor confirms future carve-outs, alternative sourcing strategies, or direct contracting arrangements will not trigger changes to the pricing of retained services.

3.8. The Contractor confirms it will support direct manufacturer contracting arrangements established by the NVHA for biosimilar products and other pharmaceutical procurement initiatives.

3.9. The Contractor confirms it will administer claims, formulary strategies, reimbursement arrangements, and reporting requirements associated with NVHA-directed biosimilar contracting arrangements.

3.10. The Contractor confirms direct manufacturer biosimilar contracting arrangements will not adversely impact financial guarantees, pricing, administrative fees, rebate guarantees, or other contractual commitments offered to the NVHA.

3.11. The Contractor confirms it will provide recurring reporting regarding PBM profitability and margin associated with the NVHA's pharmacy benefit program.

3.12. The Contractor confirms it will provide separate margin reporting for Retail, Mail, and Specialty dispensing channels.

3.13. The Contractor confirms it will provide transparency into acquisition costs, reimbursement costs, dispensing fee revenue, administrative fee revenue, manufacturer-derived compensation, and all other sources of PBM revenue and margin.

3.14. The Contractor confirms it will provide therapeutic-class level profitability reporting for GLP-1 medications, obesity therapies, specialty medications, and other high-cost drug categories as identified by the NVHA.

3.15. The Contractor confirms PBM margin reporting provided to the NVHA will be sufficiently detailed to permit independent validation by the NVHA and its designated consultant.

3.16. The Contractor confirms it will operate under a pharmacy benefit model that provides the NVHA with maximum visibility into and control over pharmacy benefit economics, including reimbursement methodologies, manufacturer revenue streams, dispensing fees, administrative fees, and PBM margin.

3.17. The Contractor confirms it will fully disclose all compensation received directly or indirectly by the Contractor, its affiliates, subcontractors, pharmacies, group purchasing organizations (GPOs), rebate aggregators, or other related entities in connection with the NVHA's pharmacy benefit program.

3.18. The Contractor confirms it will administer the NVHA's pharmacy benefit program in a manner that minimizes financial conflicts of interest and eliminates undisclosed sources of PBM revenue.

4. Help Desk & Member Experience

4.1. Help Desk

4.1.1. The Contractor shall maintain a customer service center with a toll-free telephone number staffed by trained personnel twenty-four (24) hours per day, seven (7) days per week, three hundred sixty-five (365) days per year to support Members, NVHA representatives, licensed prescribers, and participating pharmacies.

4.1.2. The Contractor must provide policies and procedures related to help desk operations and must ensure proper and thorough training of help desk staff, including on call escalation policies. Training must be specific to PEBP’s pharmacy program for front-line staff leading the Nevada help desk, and the training materials must be provided to the State for review and approval.

4.1.3. The Contractor must have policies and procedures in place for tracking help desk efficiency, results, and volume.

4.1.4. The Contractor must strive to achieve issue resolution on the first call whenever possible. Issues received via non-telephonic means must be responded to within 24 hours.

4.1.5. The Contractor must keep the help desk staffed with applicable technical and clinical personnel and must have policies and procedures for escalation to clinical personnel if requested by a Member or provider.

4.1.6. The Contractor must provide staffing plans to ensure adequate coverage of help desk responsibilities, including plans for anticipating demand and hiring staff as appropriate.

4.1.7. The Contractor must have access to backup help desk personnel and must avoid extended wait times by constantly monitoring call volume in real time to react to times of high call volume by supplying backup personnel.

4.1.8. The Contractor's help desk technology must include opportunities for researching questions related to healthcare coverage and troubleshooting.

4.1.9. The Contractor must provide a system that records all inbound and outbound calls and recordings must be made available to the State upon request. Call recordings that contain or may contain PHI, PII, payment information, or other sensitive information must be access-controlled, encrypted, retained in accordance with applicable legal and contractual requirements, and protected from unauthorized access, disclosure, alteration, or deletion in accordance with Section 14.

4.1.10. The Contractor's help desk system must maintain records of all help desk issues and provide records to the State as needed, including detailed issue notes, time stamps, issue status, and final resolution of issues for all contact methods, including but not limited to phone calls, emails, faxes, and portal inquiries. Such records must be limited to information reasonably necessary to document and resolve the issue and must be protected in accordance with applicable privacy, security, records-retention, and Section 14 requirements.

4.1.11. The Contractor's help desk technology must be state of the art, with real time call volume monitoring and the ability to monitor and report on standard help desk measurements, such as average speed of answer and abandoned call rates.

4.1.12. The call average speed of answer for eighty percent (80%) of calls is less than two (2) minutes, and ninety percent (90%) is less than five (5) minutes. The contractor shall measure the average speed of answer based on the time a caller enters a queue to the moment help desk staff answers the call. Once a call is answered by help desk staff, the help desk staff shall only place the caller on hold if it is absolutely necessary to resolve the call. In this situation, the caller shall not be on hold for more than three (3) minutes. At a minimum, ninety percent (90%) of all incoming calls shall be resolved. A resolved call shall be defined as a call in which the caller receives an accurate, professional response in accordance with the state agency’s policies and procedures. The call abandonment rate is less than three percent (3%). The contractor shall measure the call abandonment rate based on the number of abandoned calls after the caller has been on hold for one (1) minute divided by the total number of calls offered during hours of operation. The average call handle time is less than seven (7) minutes per call.

4.1.13. The Contractor shall respond to 98% of written inquiries within five business days and 100% within seven business days.

4.2. Website

4.2.1. The Contractor must maintain a PEBP pharmacy website, providing public access to standard pharmacy website information, including but not limited to items such as formularies, Provider Manuals, Billing Manuals, Prior Authorization forms and criteria, contact information, pharmacy network listings, and other necessary information.

4.2.2. The Contractor shall supply needed resources, data feeds, and information to assist NVHA staff with keeping NVHA's websites and web portals up to date. The information contained shall be updated with portal failures corrected in a timely manner as determined by the NVHA.

4.3. Member Experience

4.3.1. The Contractor shall provide the following Member Experience services. Unless otherwise identified in the Ancillary Fee Schedule, all services shall be included in the proposed Administrative Fees at no additional cost to NVHA or its Members.

a. Provide toll-free customer service for Members, NVHA representatives, and licensed prescribers.

b. Provide Members with multiple methods for locating participating pharmacies, including digital search tools, mobile applications, customer service, and other available channels.

c. Provide twenty-four (24) hours per day, seven (7) days per week access to a licensed pharmacist for clinical questions.

d. Provide customized Member communications and educational materials, including implementation, open enrollment, formulary, clinical, and benefit-related communications, at no additional cost unless otherwise identified in the Ancillary Fee Schedule.

e. Provide Members with clear explanations of prescription drug costs and Member financial responsibility, including applicable deductibles, copayments, coinsurance, accumulators, and other Cost Share information through available print or digital communications.

f. Provide targeted Member communications supporting formulary changes, clinical initiatives, preventive care, and other NVHA-approved programs.

g. Provide standard digital Member capabilities, including online prescription ordering, prescription status, benefit information, pharmacy search, health information, and educational resources.

h. Provide an online prescription pricing comparison tool displaying formulary status, estimated Member Cost Share, and multiple formulary search options prior to dispensing.

4.3.2. The Contractor shall maintain an online pharmacy directory that includes participating pharmacies, pharmacy locations, hours of operation, available services, languages spoken, and delivery options, where applicable.

4.3.3. The Contractor shall provide Member support throughout implementation and open enrollment, including educational materials, communications, customer service support, digital resources, and implementation-specific outreach.

4.3.4. The Contractor shall provide implementation materials and standard Member communication materials, including mail pharmacy return envelopes, at no additional cost unless otherwise identified in the Ancillary Fee Schedule.

4.3.5. The Contractor confirms that its digital Member portal and mobile application provide real-time, member-specific drug pricing based on the Member's actual benefit design, accumulators, deductible status, and current network pricing.

4.3.6. The Contractor confirms that its digital pharmacy comparison tool displays all available in-network pharmacy options, including retail, mail, specialty, and other applicable pharmacy channels, ranked by the lowest total Member out-of-pocket cost by default without preferential placement of Contractor-owned or affiliated pharmacies.

4.3.7. The Contractor confirms that when a prescribed medication is not the lowest-cost clinically appropriate option, its digital tools proactively identify lower-cost formulary alternatives, where appropriate, estimate Member savings, and identify applicable utilization management requirements.

4.3.8. The Contractor confirms that its digital platform proactively identifies and communicates personalized savings opportunities, including lower-cost pharmacies, lower-cost medication alternatives, manufacturer assistance programs, and opportunities to optimize days' supply or fulfillment channel.

4.3.9. The Contractor confirms that Members may search for medications before receiving a prescription and obtain an accurate estimate of expected Member Cost Share across all applicable dispensing channels using the Member's actual benefit design.

4.3.10. The Contractor confirms that Members may digitally view the real-time status of prior authorization requests, appeals, exception requests, and other clinical reviews, including expected completion dates and required next steps.

4.3.11. The Contractor confirms that its digital experience provides personalized guidance based on the Member's benefit design, deductible status, accumulator balances, formulary status, network restrictions, and clinical program eligibility.

4.3.12. The Contractor confirms that its digital platform provides proactive, personalized clinical engagement, including refill reminders, adherence support, specialty medication education, preventive care reminders, and other Member-specific outreach.

4.3.13. The Contractor shall notify NVHA of planned outages and disruptions affecting Member-facing digital platforms and provide timely updates until service is restored.

4.3.14. The Contractor confirms that it will provide NVHA with reporting on Member digital engagement, including portal and mobile application utilization, price comparison tool usage, pharmacy selection behavior, prescription savings realized through digital interventions, and other mutually agreed digital engagement metrics at least quarterly.

4.3.15. The Contractor confirms that its digital Member experience does not utilize algorithms, default settings, marketing prompts, user interface designs, or other digital mechanisms that steer Members toward Contractor-owned or affiliated pharmacies when a lower-cost or equally cost-effective network option is available, unless expressly required by NVHA's benefit design.

4.3.16. The Contractor confirms that Members may initiate and complete common pharmacy benefit transactions digitally, including mail enrollment, prescription transfers, specialty pharmacy enrollment, home delivery enrollment, payment management, and communication preferences, without requiring a telephone call.

4.3.17. The Contractor shall achieve at least 95% member satisfaction with retail, mail, and specialty services, measured using a survey tool and methodology approved by NVHA.

4.3.18. The Contractor shall conduct quarterly customer service reviews with NVHA and member-service representatives. Each review shall address Member inquiry trends, service issues, and improvement actions.

5. Training and Quality Management

5.1. User Training

5.1.1. The Contractor shall provide a training and outreach plan to the NVHA that includes plans for training NVHA staff and all users of the Contractor's solution.

5.1.2. The Contractor's training and outreach plan shall include the following:

a. Approach and scope (including all anticipated system users);

b. Training and outreach activity duration, types, and schedule;

c. Training plans for pre- and post-implementation;

d. Plans for updating training documentation and providing ad hoc training as needed following updates to the Contractor's Solution.

5.1.3. The Contractor must provide training resources to NVHA providers for common provider functions, such as submitting claims, prior authorizations, and accessing formulary and PA forms on the Contractor's website.

5.1.4. The Contractor shall provide policies and procedures for ongoing monitoring of staff performance to identify any needs for supplemental training.

5.2. Training Procedures

5.2.1. The Contractor shall provide policies and procedures for evaluation of the training procedures, including how updates to training practices will be implemented.

5.3. Training Environment

5.3.1. The Contractor shall create and maintain a training and testing environment that holds the same functionality as the solution system and accurately simulates the production environment.

5.3.2. The Contractor shall use de-identified, masked, synthetic, or otherwise non-production data in training and testing environments whenever reasonably practicable. NVHA production data shall not be used in a training, development, or testing environment unless expressly approved by NVHA and protected by security controls equivalent to those applied in production. Training and testing environments shall remain appropriately segregated from production.

5.4. Quality Procedures

5.4.1. The Contractor shall provide policies and procedures for maintaining quality standards of both the Contractor and the NVHA.

5.4.2. The Contractor shall maintain the results of each quality assurance test of the solution and provide this information to the NVHA upon request.

5.4.3. The Contractor shall create and operate a quality assurance program that analyzes the Contractor's data to:

a. Audit quality assurance results

b. Provide consistent and systematic measurement comparison with Standards;

c. Monitor for errors in the solution or in other programs;

d. Determine where gaps in quality exist and develop a plan to resolve the issues.

5.4.4. The Contractor's quality assurance plan shall include policies and procedures for a user testing plan that ensures the final solution, whether it be a new solution or an upgrade, meets the quality standards of both the Contractor and the NVHA.

5.5. Prior Authorization Training

5.5.1. The Contractor must provide policies and procedures for the training and competence of reviewers for the prior authorization program.

5.5.2. The Contractor must provide a quality assurance plan for the prior authorization program responsibilities. The plan must include ensuring adequate timing of authorization reviews and consistency among reviewers. This plan must be submitted to the State for approval and must be approved annually.

5.6. Other Training Requirements

5.6.1. The Contractor shall provide the NVHA with NCPDP payer specifications that include, but are not limited to, user resource and reference documents and training materials in an easily accessible data storage or online location.

5.6.2. The Contractor shall provide their HIPAA training process to the NVHA.

5.6.3. The Contractor shall maintain a program to monitor the help desk for quality standards and develop a plan for addressing any issues in quality that may arise, including those that arise from member complaints.

6. Formulary Management

6.1. The Contractor shall administer the formulary selected by NVHA, including (i) Contractor’s standard formulary, (ii) a customized formulary derived from Contractor’s standard formulary, or (iii) an NVHA-developed or NVHA-designated third-party formulary. The Contractor shall implement and maintain the selected formulary and related coverage rules, edits, and updates in accordance with mutually agreed implementation timelines and operational specifications. If NVHA elects an NVHA-developed or third-party formulary, any incremental fees for non-standard administration services shall be subject to mutual written agreement in advance and documented in the applicable fee schedule or contract amendment. The Contractor shall not require adoption of Contractor’s standard formulary as a condition of providing PBM services.

6.2. In the event of any formulary, tier, coverage, or utilization management change that increases Member Cost Share or reduces member access, including an exclusion, removal, up-tier, or new or more restrictive utilization management requirement, the Contractor shall provide detailed analytics at least ninety (90) days prior to the effective date of the change. Analytics must include affected drugs, therapeutic alternatives, impacted Members, claim counts, gross and net cost impact, Member Cost Share impact, rebate impact, and proposed member and provider communications.

6.3. Within thirty (30) business days of any formulary change announcement, the Contractor shall provide the clinical rationale for the change and identify the NVHA’s available decision options, including whether the NVHA may adopt, reject, delay, grandfather, or customize the change. The Contractor must also identify any operational, Member access, Member Cost Share, or financial guarantee implications associated with each available option.

6.4. The Contractor shall notify Members at least sixty (60) days prior to the effective date of any formulary, tier, coverage, or utilization management change that increases Member Cost Share or reduces Member access. Contractor will provide all Member and provider communication templates to NVHA for review and approval before distribution.

6.5. Prior to making any formulary modification, Contractor shall advise NVHA of the impact to Members and / or NVHA, including gross cost, net cost, Member Cost Share, rebate value, manufacturer administrative fees, price protection, affiliate compensation, clinical outcomes, Member access, and operational requirements.

6.6. Where newly launched drugs are in a therapeutic area with other treatment options currently available, the Contractor shall describe whether and under what circumstances it blocks these new drugs from its standard formularies for up to 180 days, i.e., New-To-Market Block. The Contractor must describe the clinical review process, exception process, communication approach, and timing for the NVHA to override or provide coverage approval.

6.7. The NVHA has the right to override any New-To-Market block where NVHA determines coverage is clinically appropriate or in the best interest of the Plan or Members. Any proposed financial guarantee adjustment associated with such override must be transparent, limited to the demonstrated impact of the specific override, supported by drug-level or claim-level documentation, and approved by the NVHA in writing prior to implementation.

6.8. The NVHA has the right to exclude medications on the Contractor's standard formulary that are considered low value medications and / or prefer medications with a lower net cost based on the NVHA’s determination of clinical value, net cost, Member impact, fiduciary considerations, or availability of clinically appropriate alternatives. The Contractor shall support such exclusions or preferences through benefit setup, claims adjudication, Member and provider communications, and reporting.

6.9. Upon request and within an agreed timeframe, the Contractor shall share the detailed methodology employed to calculate cost savings and cost avoidance for a specific drug class.

6.10. The Contractor shall provide recommendations for optimizing cost avoidance or savings potential, considering the availability of generic products.