41NHA-S3992 - sPBM Exhibit B - Definitions~1.docx
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- Attached to
- Nevada State Pharmacy Benefit Manager
- Solicitation number
- 41NHA-S3992
- Issued by
- Nevada
About this file
This document is Exhibit B of the Nevada State Pharmacy Benefit Manager RFP issued by the Nevada Health Authority, containing comprehensive definitions for acronyms and terms used throughout the procurement. The exhibit provides standardized definitions for over 80 terms and abbreviations relevant to pharmacy benefit management operations, including federal programs (340B Drug Pricing Program), pricing methodologies (Average Manufacturer Price, Wholesale Acquisition Cost, National Average Drug Acquisition Cost), clinical review processes (Drug Utilization Review, Concurrent Drug Utilization Review, Medication Therapy Management), and regulatory frameworks (HIPAA, HITECH Act, CMS regulations). Key operational terms are defined, including those related to claims processing, prior authorization, rebate programs, pharmacy networks, and benefit administration functions that the selected PBM contractor will be responsible for managing on behalf of Nevada Medicaid members.
The definitions establish a common lexicon for evaluating bidder proposals and contract performance, addressing technical pharmacy operations such as Point of Sale processing, Electronic Prior Authorization, Coordination of Benefits, and Fraud, Waste, and Abuse detection. Additionally, the exhibit defines governance and compliance-related terms including the Nevada Pharmacy Oversight Plan, Business Associate Agreements, Data Sharing Agreements, Business Continuity Plans, Disaster Recovery Plans, and security standards referenced in the RFP. This standardization ensures that all prospective contractors understand the specific requirements, operational parameters, and regulatory obligations associated with serving as Nevada's single Pharmacy Benefit Manager for Medicaid pharmacy benefits administration.
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41NHA-S3992 - NV PBM RFP Exhibit B – Definitions for acronyms and terms
Definitions for acronyms and terms appear below.
| Acronym |
| Expanded Term |
| Definition |
| 340B |
| 340B Drug Pricing Program |
| A federal program that allows eligible covered entities to buy outpatient drugs at reduced prices. |
| 340B Ceiling Price |
| 340B Ceiling Price |
| The unit price of a 340B drug, arrived at by calculating each NDC's AMP minus URA. |
| AMP |
| Average Manufacturer Price |
| The price a manufacturer charges wholesalers or pharmacies that purchase directly from the manufacturer after discounts. |
| AR |
| Accounts Receivable |
| Amounts owed and tracked for rebate reconciliation and accounting. |
| ASP |
| Average Sale Price |
| A calculation weighted average of manufacturer sales price for a drug for all purchasers. |
BAA
| Business Associate Agreement |
| An agreement establishing HIPAA privacy, security, breach-notification, and data-handling obligations applicable to a business associate. |
| Beneficiary |
| Beneficiary |
| A Medicaid member who receives covered pharmacy benefits. |
| BCP |
| Business Continuity Plan |
| A plan for keeping essential operations running during a disruption. |
| Bi-Weekly |
| Bi-Weekly |
| No less frequently than every two (2) weeks (twenty-six (26) payment cycles per contract year), on a schedule aligned with the Contractor's claims adjudication cycle. |
| CDUR |
| Concurrent Drug Utilization Review |
| A near-real-time review of claims to identify and resolve possible issues such as drug-disease interactions and drug-drug interactions. |
| CMS |
| Centers for Medicare & Medicaid Services |
| The federal agency that oversees Medicare and Medicaid and sets many of the requirements referenced in the RFP. |
| CMS Accessibility Standards |
| CMS Accessibility Standards |
| CMS's commitment to making its electronic and information technologies accessible to people with disabilities, based on Section 508 of the Rehabilitation Act (29 U.S.C. 794d) of 1998. |
| CMS Certification Process |
| CMS Certification Process |
| The process used to obtain CMS approval or certification for the Contractor’s Solution and related components. |
| CMS Interoperability and Patient Access Rule |
| CMS Interoperability and Patient Access Rule |
| A CMS rule (CMS-9115-F) requiring interoperability, data sharing, and patient access capabilities. |
| COB |
| Coordination of Benefits |
| The process used by insurers to determine which health plan pays first and how secondary plans cover remaining costs when a person has multiple insurance policies. |
| CPT |
| Current Procedural Terminology |
| A standard coding system for medical services and procedures. |
| Data Sharing Agreement |
| Data Sharing Agreement |
| The agreement that governs how NVHA data is accessed, used, protected, and shared. |
| DRP |
| Disaster Recovery Plan |
| A plan for restoring systems and operations after a disruption or disaster. |
| DUR |
| Drug Utilization Review |
| A clinical and claims review process used to evaluate medication use for safety, appropriateness, and cost. |
| ePA |
| Electronic Prior Authorization |
| An electronic method for submitting and processing prior authorization requests. |
| EFT |
| Electronic Funds Transfer |
| The electronic transfer of funds between parties for reimbursement or other payments. |
| FDA |
| Food and Drug Administration |
| The federal agency responsible for drug approval and related regulatory oversight. |
| FDB |
| First DataBank |
| A commercial drug pricing and reference data source used in pharmacy systems. |
| FFS |
| Fee-for-Service |
| A Medicaid delivery model in which the NVHA pays providers directly for covered services. |
| FTE |
| Full-Time Equivalent |
| A measure of staffing based on the workload of one full-time employee. |
| FUL |
| Federal Upper Limit |
| A price ceiling used by CMS to control price for certain medications paid to pharmacies. |
| FWA |
| Fraud, Waste, and Abuse |
| Improper or abusive activity involving Medicaid or pharmacy claims. |
| GNUP |
| Guaranteed Net Unit Price |
| A rebate arrangement that guarantees a specific net price per drug unit. |
| HCPCS |
| Healthcare Common Procedure Coding System |
| A standard coding system used for medical services, supplies, and some drugs. |
| HITECH |
| Health Information Technology for Economic and Clinical Health Act |
| A federal law that strengthens HIPAA privacy and security protections for electronic health information. |
| HIPAA |
| Health Insurance Portability and A preset financial penalty for failing to meet contract requirements. |
Accountability Act The federal law governing the privacy and security of health information.
| ICD-9 |
| International Classification of Diseases, Ninth Revision |
| A diagnosis coding system used in claims and prior authorization logic. |
| ICD-10 |
| International Classification of Diseases, Tenth Revision |
| A diagnosis coding system used in claims and prior authorization logic. |
| IT |
| Information Technology |
| The systems, technology, and support functions that enable claims processing and data exchange. |
| MAC |
| Maximum Allowable Cost |
| A price ceiling, similar to FUL, established at the NVHA level. |
| MCO |
| Managed Care Organization |
| A managed care health plan that receives Medicaid funding and manages covered services for enrolled members. |
| Medicaid Drug Utilization Review Annual Report Survey |
| Medicaid Drug Utilization Review Annual Report Survey |
| The CMS annual survey used to report Medicaid drug utilization review activities. |
MFA
| Multi-Factor Authentication |
| Authentication requiring two or more distinct factors before access is granted. |
| MTM |
| Medication Therapy Management |
| Pharmacist-led services that evaluate medication use to improve safety, effectiveness, and cost control. |
| NAC |
| Nevada Administrative Code |
| Nevada’s administrative rules that implement state law requirements. |
| NADAC |
| National Average Drug Acquisition Cost |
| A CMS rate file designed to create a benchmark that is reflective of the prices paid by retail community pharmacy to acquire prescription drugs and OTC covered outpatient drugs. |
| NCPDP |
| National Council for Prescription Drug Programs |
| The organization that develops pharmacy transaction and data standards. |
| NDC |
| National Drug Code |
| A unique identifier for drug products used in claims, pricing, and rebate programs. |
| Nevada Pharmacy Oversight Plan |
| Nevada Pharmacy Oversight Plan |
| The NVHA-approved plan for reviewing and overseeing pharmacy benefit operations. |
| NIST |
| National Institute of Standards and Technology |
| The federal standards body whose security controls are referenced in the RFP. |
| NVHA |
| Nevada Health Authority |
| Nevada Health Authority |
| NRS |
| Nevada Revised Statutes |
| Nevada laws that apply to confidentiality, records, privacy, security, and related requirements. |
| PA |
| Prior Authorization |
| A review and approval process required before certain drugs or services are covered or paid. |
| PAD |
| Physician Administered Drug |
| A drug administered by a provider, often billed under the medical benefit. |
| PBA |
| Pharmacy Benefit Administration |
| The administration of pharmacy benefits, including claims, pricing, rebates, and related operations. |
| PBM |
| Pharmacy Benefit Manager |
| A contractor that administers prescription drug benefits, including claims processing, network management, prior authorization, DUR, and reporting. |
| PDL |
| Preferred Drug List |
| The NVHA-approved list of preferred medications for coverage and reimbursement. |
PHI
| Protected Health Information |
| Individually identifiable health information protected under HIPAA |
PII
| Personally Identifiable Information |
| Information that identifies or can reasonably be linked to an individual. |
| POS |
| Point of Sale |
| The real-time environment where pharmacy claims are processed at the pharmacy counter. |
| Readiness Review |
| Readiness Review |
| A pre-go-live review used to confirm that the solution and implementation are ready for production. |
RPO
| Recovery Point Objective |
| The maximum acceptable amount of data loss measured in time following a disruption. |
RTO
| Recovery Time Objective |
| The targeted maximum time to restore a system or service following a disruption. |
| Silver State Script Board |
| Silver State Script Board |
| Nevada’s pharmacy and therapeutics committee |
| SMAC |
| State Maximum Allowable Cost |
| Nevada’s state-specific MAC file or reimbursement benchmark used in claims pricing. |
| sPBM |
| Single Pharmacy Benefit Manager |
| The sole PBM responsible for administering pharmacy benefits for all Nevada Medicaid members. |
SOC 2
| System and Organization Controls 2 |
| An independent examination of controls relevant to security, availability, processing integrity, confidentiality, or privacy. |
| SOW |
| Scope of Work |
| The work, services, and deliverables required under the contract. |
SSP
| System Security Plan |
| Documentation describing system boundaries, architecture, security controls, responsibilities, and the operating environment. |
| State |
| State |
| The State of Nevada and its agencies, departments, and representatives administering the contract. |
| Supplemental Rebate Contracts |
| Supplemental Rebate Contracts |
| Manufacturer agreements that provide rebates in addition to federal Medicaid rebates. |
| TPL |
| Third Party Liability |
| Other insurance coverage that may be responsible for payment before Medicaid pays. |
| UAT |
| User Acceptance Testing |
| Testing performed by the NVHA and/or users to confirm the solution meets business requirements before go-live. |
| UM |
| Utilization Management |
| Clinical controls used to manage drug use, such as prior authorization, step therapy, quantity limits, edits, and formulary controls. |
| URA |
| Unit Rebate Amount |
| The statutory per-unit rebate amount used in Medicaid drug rebate calculations. |
| UROA |
| Unit Rebate Offset Amount |
| A rebate-related factor used in rebate calculations and analysis. |
| VBP |
| Value-Based Purchasing |
| A contracting model that links payment to outcomes, performance measures, or other value metrics. |
| Contractor |
| Contractor |
| The contractor or offeror responsible for delivering the requested services. |
| Contractor's Solution |
| Contractor's Solution |
| The Contractor’s proposed system, processes, products, and related services. |
| WAC |
| Wholesale Acquisition Cost |
| The manufacturer’s list price, used in pricing and rebate calculations. |
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