41NHA-S3992 - sPBM Scope of Work~1.docx

Nevada State Pharmacy Benefit Manager

Pursuant to 41NHA-S3992

Director’s Office

Joseph Lombardo Governor State of Nevada

Stacie Weeks, JD MPH Director Nevada Health Authority

Table of Contents

1. General Expectations and Qualifications 6-9

1.1 General Contract Requirements.…………………………………………………………………..…….6

1.2 Business Hours..…………………………………………………………………………………….…..…….6

1.3 Experience……………………………………………………………………………………………………….6

1.4 Security……………………………………………………………………………………………..…………

1.5 CMS Requirements……………………………………………………………………………..……….……7

1.6 Regulatory Requirements…………………………………………………………………………..……….7

1.7 NCPDP………………………………………………………………………………………………….….……..8

1.8 NVHA Requirements……………………………………………………………………………….….……..8

1.9 Transitions…………………………………………………………………………………………….….……..9

1.10 Alternative Payment Arrangements……….……………………………………………….….……….9

2. Staffing……………………………………………………………………………………………….…10-15

3. Single PBM (sPBM) Overview…………………………………………………………………….15-18

3.1 Phased Implementation and Coverage………………………………………………..……….…..…15

3.2 NVHA Oversight and Dispute Resolution……………………..…………………………….......….15

4. Help Desk, Website, and Portal…………………………………………………………………18-20

4.1 Hours of Operation……………………………………………………………………………………..……18

4.2 Policies and Procedures………………………………………………………………………..…..……..18

4.3 Staffing…………………………………………………………………………………..……………….……..19

4.4 Technology……………………………………………………………………………………………

4.5 Website………………………………………………………………………………..…………….....……...20

4.6 Portal……………………………………………..………………………………………….……….…..…….20

5. Training and Quality Management…………………………………………………………..…20-23

5.1 User Training……………………………………………………………………………………….………….20

6. PDL……………………………………………………………………………………..……………..…23-24

6.1 Management and Maintenance of the Medicaid Single Preferred Drug List (PDL)……….23

7. DUR UM and Care Coordination………………………………………………………….…….25-31

8. PAD Program………………………..……………………………………………………………..…32-33

9. VBP…………………………………………………………………………………………………....…33-34

10. Clinical Programs………………………………………………………………………………….34-35

11. Fraud, Waste, and Abuse (FWA)……………………………………………….………………35-37

12. Reporting……………………………….………………………………………….…………………37-42

13. Certifications………………………………………………………………………………….…………42

13.1 Overview……………………………………….………………………………………………….………….42

14. Security and IT Solutions……………………………………………………..…………………42-55

15. Price Files………………………………………………………………..………………………..…55-57

16. Rebates………………………………………………………………………………………….……57-65

17. Claims Processing………………………………….……………………………………….….…65-70

18. Pharmacy Networks………………………………………………………………….………..…70-71

19. Implementation………………………………………………………………………..…….….…71-74

20. Offboarding………………………………………………………………………….………….……74-81

21. Key Performance Measures and Performance Credits…………………….….…….81-82

22. Federal Penalties……………………………………………………………………………….………82

23. Exhibit Index…………………………………………………………………………….……….………82

1 General Expectations and Qualifications

1.1 General Contract Requirements

1.1.1 Contractor shall provide comprehensive Pharmacy Benefit Manager (PBM) services to support the full Nevada Medicaid pharmacy benefit across all populations, including Fee‑for‑Service (FFS) and Managed Care Organizations (MCOs). Contractor shall perform all functions necessary to administer the statewide pharmacy benefit, including claims adjudication; formulary and preferred drug list development and maintenance; pharmacy network management; drug rebate negotiation, invoicing, and administration; and clinical and utilization management activities that promote cost‑effective prescribing and improved clinical outcomes. The services provided under this Agreement shall fully support Nevada Medicaid’s benefit design, operational requirements, and compliance obligations, and Contractor shall coordinate effectively with FFS operations, all contracted MCOs, and any other State‑designated entities to ensure integrated, transparent, and consistent pharmacy benefit administration that advances fiscal stewardship, program integrity, and optimal health outcomes for the Nevada Medicaid population.

1.2 Business Hours

1.2.1 The Contractor shall be available during normal, Pacific Time, business hours, Monday through Friday, 8:00 AM to 5:00 PM (PT) with the pharmacy helpdesk being available 24 hours per day, 7 days per week, 365 days per year.

1.3 Experience

1.3.1 The Contractor shall have at least five (5) years of experience providing pharmacy management services for a state Medicaid program (Fee-For-Service (FFS) or Managed Care Organization (MCO)).

1.4 Security

1.4.1 The Contractor shall comply with all security, privacy, confidentiality, data-protection, and technology requirements established in Section 14, together with all applicable legal, regulatory, contractual, and State requirements.

1.4.2 Before receiving or accessing NVHA systems or data, the Contractor shall execute any Business Associate Agreement, Data Sharing Agreement, Data Use Agreement, confidentiality agreement, or other data-protection agreement required by the NVHA.

1.4.3 The Contractor shall ensure that the requirements of Section 14 are applied to all subcontractors, sub processors, third-party service providers, and personnel supporting the contracted services.

1.5 CMS Requirements

1.5.1 The Contractor shall participate in and commit to facilitating a successful CMS Certification process for the entire contract period, including extensions, if any.

1.5.2 The Contractor shall also complete all necessary duties and tasks to assist the NVHA in securing CMS certification for the Contractor's Solution and related components.

1.5.3 The Contractor shall provide documentation to the NVHA that all CMS accessibility standards are being met.

1.5.4 The Contractor shall actively participate and work with the NVHA on complying with the CMS Interoperability and Patient Access Rule.

1.5.5 The Contractor shall create, operate, and maintain processes or systems to provide compliant data required for monthly and historical CMS T-MSIS submissions within NVHA-specified timeframes.

1.6 Regulatory Requirements

1.6.1 The Contractor's services and systems provided under the Contract shall be in compliance with all federal Medicaid requirements for the coverage, service delivery, payment, rebates, and reporting with regards to outpatient prescription drugs. The Contractor's Solution shall be maintained and enhanced by the Contractor to incorporate any new federal requirements by the mandated federal effective dates.

1.6.2 The Contractor's services and systems provided under the Contract shall be in compliance with all State of Nevada requirements for the coverage, service delivery, payment, rebates, and reporting with regards to outpatient prescription drugs. The Contractor's Solution shall be maintained and enhanced by the Contractor to incorporate any new State requirements by the mandated State effective dates.

1.7 NCPDP

1.7.1 The Contractor shall be a current National Council for Prescription Drug Program (NCPDP) member and maintain membership throughout the life of the contract.

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

1.8 NVHA Requirements

1.8.1 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 by NVHA to the Contractor’s policy and procedure documents and all related business and clinical plans.

1.8.2 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 by NVHA to the Contractor’s policy and procedure documents and all related business and clinical plans.

1.8.3 The Contractor shall develop and provide an internal quality control program to ensure fulfillment of all activities assigned to the Contractor by the NVHA.

1.8.4 The Contractor shall provide documentation of the recommended and current configuration, demonstration of business processes using recommended configuration, and provide examples of possible customizations, where approved by the NVHA.

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

1.8.6 The Contractor shall participate and work with additional contractors serving the NVHA.

1.8.7 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.

1.9 Transition

1.9.1 The Contractor shall have a task-specific and time-limited transition plan that will successfully implement Contractor responsibilities upon initiation of the contract, and transfer Contractor activities upon termination of the contract without interrupting services to program members.

1.9.2 The Contractor shall coordinate with the current contractor to ensure a smooth transition without interrupting services to program members.

1.9.3 The Contractor shall ensure that any outstanding rebate amounts received after contract closeout are transferred to the NVHA.

1.10 Alternative Payment Arrangements

1.10.1 The Contractor's proposal shall address the Contractor's ability and willingness to amend agreements to accommodate alternate payment arrangements as deemed necessary by the NVHA.

2. Staffing

2.1. Staffing Plan

2.1.1. The Contractor shall create and maintain an NVHA-approved Staffing Plan to meet all contractual requirements.

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

2.1.3. The Staffing Plan shall 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. All Contractor, subcontractor, sub processor, and third-party personnel who perform contracted services or access State systems or data shall be located and perform work within the United States. State data shall not be accessed, processed, stored, transmitted, administered, or supported outside the United States unless expressly approved in writing by the NVHA. The Contractor shall remain fully responsible for compliance by all personnel and supporting entities.

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

2.1.6. 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.

2.1.7. 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.

2.2. Key Personnel Qualifications

2.2.1. 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.

2.2.2. Key personnel should be based in Nevada; those outside Nevada require NVHA approval. Any other proposed deviations from Key Personnel requirements shall be approved by the NVHA.

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).

2.2.4. At least one key personnel shall be available 24/7 as required by the NVHA.

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

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

2.2.7. 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.

2.3. Key Personnel

2.3.1. Program Manager:

2.3.1.1. The Contractor shall provide a Program Manager, as the primary point of contact between the NVHA and the Contractor, responsible for coordinating communication, deliverables, and progress. This individual will oversee the clinical and operational aspects of the contract, possessing decision-making authority for ongoing operational activities. The proposed Program Manager candidate must be presented to NVHA for interview and approval prior to placement, and the position shall be filled within thirty (30) calendar days of NVHA’s authorization.

2.3.2. Project Manager

2.3.2.1. The Contractor shall provide a Project Manager to oversee change requests for the Solution and facilitate the transition from implementation to operations. This role requires experience in Pharmacy Benefit Administration (PBA) or Pharmacy Benefit Manager (PBM) operations, along with knowledge of project management standards. The Project Manager position shall be filled within thirty (30) calendar days of NVHA’s authorization.

2.3.3. Information Technology (IT) Coordinator

2.3.3.1. The Contractor shall provide an IT Coordinator to serve as the designated point of contact between the NVHA and the Contractor for all technical aspects of the Solution. The IT Coordinator will have decision-making authority on behalf of the Contractor concerning all technical matters related to the contract and will be primarily responsible for coordinating all systems and data aspects of the contract in support of the NVHA. The IT Coordinator position shall be filled within sixty (60) calendar days of receiving authorization from the NVHA.

2.3.4. Fraud, Waste, and Abuse (FWA) Lead

2.3.4.1. The Contractor shall provide a FWA Lead who will be responsible for all FWA matters. The FWA position shall be filled within sixty (60) calendar days of receiving authorization from the NVHA.

2.3.5. Pharmacists

2.3.5.1. The Contractor shall provide sufficient licensed pharmacist support to fulfill all requirements of the contract and must include at least two with active Nevada licensure. Nevada-licensed pharmacists may also serve as the Program Manager (2.3.1.1) at the Contractor’s discretion and subject to NVHA’s approval. The pharmacists are responsible for managing and implementing utilization management (UM) policies, UM recommendations, and related documentation. Additional pharmacists to support clinical help desk functions shall not be included in the minimum number of pharmacists specified in this section.

2.3.6. Implementation Manager

2.3.6.1. The Contractor shall provide an Implementation Manager with proven experience in implementation management for a State or a similar organization. The Contractor’s Implementation Manager will be a key position that will oversee all aspects of solution configuration, planning, and deployment. The Contractor shall retain this position at the sole discretion of the NVHA, which includes, at a minimum, the entire implementation phase and transition to steady-state maintenance phase.

2.3.7. Certification Lead

2.3.7.1. The Contractor shall provide a Certification Lead with proven experience in achieving CMS certification throughout the entire certification process, including obtaining certification approval and any other necessary CMS or other regulatory approvals. The Contractor’s Certification Lead will be a key position responsible for developing a strategy for proper documentation to support certification, creating metrics to facilitate certification, and assisting the NVHA in its engagement and interaction with CMS and any other necessary entities to secure full approval of the Contractor’s solution. The Contractor’s Certification Lead shall be available throughout all certification activities and upon NVHA’s request.

2.3.8. Quality Manager

2.3.8.1. The Contractor shall provide a Quality Manager to oversee quality management activities, including quality planning, quality assurance, and quality control. The Contractor’s Quality Manager will be a key position responsible for leading the Quality Assurance Unit in maintaining consistent excellence in the delivery of all products and services related to this contract, as well as ensuring the competence levels of the staff responsible for delivering those services. Throughout the development and implementation life cycle, the Quality Manager will collaborate with both Contractor and the NVHA staff to create a comprehensive test suite aimed at eliminating defects from reaching the production environment.

2.3.9. Help Desk Manager

2.3.9.1. The Contractor shall provide a Help Desk Manager to oversee all clinical and operational functions of the help desk team. The Help Desk Manager shall be responsible for ensuring quality service is delivered by the team via phone, email, mail, portal, and any other means of patient and provider contact, both inbound and outbound.

2.3.10. PDL Manager

2.3.10.1. The Contractor shall provide a PDL Manager who will negotiate supplemental rebates on behalf of the NVHA and lead all PDL processes and procedures. The position shall be a licensed pharmacist and shall be filled 120 calendar days prior to the go-live date.

2.4. Additional Personnel

2.4.1. The Contractor shall designate and commit the following personnel and staff, in addition to Key Personnel, to perform the services under this Contract.

2.4.1.1. Quality Assurance Unit: This unit should be part of the Contractor’s organization but not involved in implementation or operations. It shall be adequately staffed to ensure high-quality delivery of products and services.

2.4.1.2. Clinical Benefits Analyst: This position oversees implementation and testing of necessary Utilization Management changes and coding updates in the Contractor's Solution.

2.4.1.3. Senior Developer: A Senior Developer is needed to analyze business requirements and implement modifications to the Contractor's Solution.

2.4.1.4. Training and Application Support Staff: Full-time staff are required to ensure adequate training for all users of the Contractor's Solution.

2.4.1.5. Report Writer: This position leads creation of all contractually required and regulatory reports, and any ad hoc report requests.

2.4.1.6. Data Analyst: A Data Analyst is required for statistical and financial analysis, with experience in state Medicaid claims, drug trend analysis, and large healthcare databases.

2.4.1.7. Pharmacy Drug Rebate Subject Matter Expert (SME): A SME is needed to oversee the drug rebate program, with experience in federal and state-specific rebate programs. This position oversees all rebate invoicing and collections, and rebate dispute resolution.

2.4.1.8. Additional Qualified Staff: The Contractor shall have additional qualified personnel with expertise in various areas, including Medicaid pharmacy programs, pharmacy benefit management, clinical support, fraud prevention, and strategic planning."

2.5. Quality Assurance and Training

2.5.1. The Contractor shall 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.

3. Single PBM (sPBM) Overview

3.1. Phased Implementation and Coverage

3.1.1. The Contractor shall provide comprehensive pharmacy benefit management (PBM) coverage for all Nevada Medicaid and Nevada Check Up members via a phased implementation:

a. Contract Year 1: Coverage shall apply strictly to Fee-for-Service (FFS) members.

b. Contract Year 2 and Thereafter: Coverage shall expand to include all members enrolled in managed care, with the Contractor operating as the State Pharmacy Benefit Manager across both FFS and MCO delivery for all Nevada Medicaid and Nevada Check Up members.

3.2. NVHA Oversight and Dispute Resolution

3.2.1. NVHA retains absolute oversight authority over all Contractor activities executed under this Agreement. NVHA shall facilitate and ensure operational coordination between the Contractor and participating MCOs. In the event of any administrative, operational, or financial dispute between the Contractor and an MCO, NVHA shall serve as the final authority, and the Contractor shall strictly comply with all NVHA determinations.

3.3. Mandatory MCO Contracting Requirements

3.3.1. Contractor shall enter into a separate contract with each Nevada Medicaid MCO using a standard agreement in a form prescribed and approved in writing by NVHA. Without exception, these MCO agreements must explicitly incorporate provisions securing the following operational capabilities:

a. Administrative Fees & Reimbursements: Mechanisms for the Contractor to receive NVHA-approved administrative fees from each MCO, alongside the biweekly transfer of pharmacy reimbursement funds from the MCOs to the Contractor.

b. Data Sharing & System Interfaces: Protocols for bi-directional data sharing, care coordination, file transfers, and system integration utilizing current and future NCPDP data standards.

c. System Access: Real-time NVHA and MCO access to the Contractor's point-of-sale claims processing system.

d. Member & Provider Coordination: Protocols to resolve member and provider inquiries, including automated call center transfers, claims troubleshooting, and the processing of complaints, grievances, and appeals.

e. Regulatory Reporting: Mandatory data-sharing to support MCO care management statistics and state and federal regulatory reporting.

f. Pharmacy Expenditure Reporting: shall collect, process, and transmit pharmacy benefit expenditure data obtained from each MCO to the NVHA upon request in the formats and timeframes designated by the NVHA.

3.4. Uniformity of Performance

3.4.1. The Contractor shall perform all pharmacy benefit management functions uniformly across all covered populations, regardless of a member's FFS or MCO enrollment status, to eliminate duplication of effort and minimize administrative friction.

3.5. Marketing and Member Communications

3.5.1. The Contractor's Key Personnel shall coordinate directly with each MCO to ensure that all required prescription billing data and pharmacy benefit information are accurately integrated into member ID cards, printed assets, web-based portals, and any other published materials distributed by the MCO.

3.6. Continuity of Network Adjustments

3.6.1. The Contractor shall deliver all contracted services in alignment with NVHA’s managed care network. The Contractor acknowledges that NVHA may add, remove, or substitute participating MCOs over time. The Contractor shall onboard and integrate any such MCO changes in strict compliance with NVHA-defined timelines and processes.

3.7. Eligibility File Processing

3.7.1. The Contractor shall ingest, load, and utilize Member eligibility files at a frequency designated by 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.

3.8. Payment to Pharmacies

3.8.1. The Contractor shall reimburse pharmacies in full for adjudicated claim costs using the funds the Contractor is paid by the MCOs for those claims, which reflect the actual claim costs for the NVHA-defined payment period. The Contractor shall reimburse pharmacies in full for Fee-for-Service (FFS) adjudicated claim costs using the FFS claims payments the Contractor receives directly from the NVHA.

3.8.2. The Contractor shall receive its administrative fee from the MCOs and from NVHA for the FFS program at a NVHA-defined frequency, and shall return to NVHA any funds associated with assessed penalties or claims paid in error.

3.9. Conflict of Interest & Fee Disclosure

3.9.1. 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.

3.9.2. 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.

3.9.3. 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.

4. Help Desk, Website, and Portal

4.1. Hours of Operation

4.1.1. The Contractor's help desk shall be available to members and providers twenty-four (24) hours per day, seven (7) days per week, three hundred sixty-five (365) days a year.

4.2. Policies and Procedures

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

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

4.2.3. The Contractor shall strive to achieve issue resolution on the first call whenever possible. Issues received via non-telephonic means shall be resolved or processed to a final determination within 24 hours.

4.2.4. 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.

4.3. Staffing

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

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

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

4.4. Technology

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

4.4.2. The Contractor shall provide a system that records all inbound and outbound calls and recordings shall be made available to the NVHA upon request.

4.4.3. The Contractor's help desk system shall maintain records of all help desk issues and provide records to the NVHA 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.

4.4.4. The Contractor's help desk technology shall employ real time call volume monitoring and have the ability to monitor and report on standard help desk measurements, such as average speed of answer and abandoned call rates.

4.4.5. Call recordings, issue records, case notes, emails, faxes, portal inquiries, and other help desk records containing NVHA data shall be treated as NVHA data and protected in accordance with Section 14. Access shall be limited to authorized personnel with a legitimate business need. The Contractor shall maintain NVHA-approved retention and secure disposal processes for such records and shall not use the records for secondary purposes not authorized by NVHA.

4.5. Website

4.5.1. The Contractor shall maintain a Nevada Medicaid pharmacy website, providing public access to standard pharmacy website information, including but not limited to items such as PDLs, Provider Manuals, Billing Manuals, Prior Authorization forms and criteria, contact information, pharmacy network listings, and other necessary information. The information contained shall be updated with website failures corrected in a timely manner as determined by the NVHA.

4.6. Portal

4.6.1. 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. (https://www.medicaid.nv.gov/)

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

5.1.4. The Contractor shall provide NVHA staff with the ability to view the provider's website and systems for troubleshooting and training purposes.

5.1.5. 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. Quality Assurance Testing

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

5.4.2.2. 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 developing a plan to resolve the issues.

5.4.3. Quality Assurance Plan

5.4.3.1. 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.

5.4.4. Prior Authorization Training

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

5.4.5. Prior Authorization Quality Assurance

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

5.4.6. NCPDP

5.4.6.1. 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.

5.4.7. HIPAA

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

5.4.8. Help Desk Quality Assurance

5.4.8.1. 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. PDL

6.1. Management and Maintenance of the Medicaid Single Preferred Drug List (PDL)

6.1.1. The Contractor shall deliver a comprehensive suite of services to establish and oversee all elements of the NVHA, Nevada Medicaid single PDL, encompassing both pharmaceutical and non-pharmaceutical products.

6.1.2. The Contractor shall manage and coordinate all aspects of the Nevada Medicaid single PDL including Prior Authorization (PA), Step Therapy and Quantity Limit edits as specified by the NVHA. Drugs are reviewed by the State's Silver State Script Board and all PDL changes shall be completed within the timeframe established by the NVHA.

6.1.3. The Contractor shall conduct clinical and financial assessments and provide recommendation for NVHA action regarding new brand and generic drugs, new indications (both on-label and off-label) for existing drugs, and new formulations and strengths.

6.1.4. The Contractor shall supply recommended clinical prior authorization criteria and quantity limits for covered outpatient drugs.

6.1.5. At least quarterly, the Contractor shall analyze pharmacy claims data to identify the top therapeutic drug classes by expenditure and volume based on actual utilization.

6.1.6. The Contractor shall analyze prescribing patterns and member behaviors to develop and execute effective engagement strategies and optimize PDL design.

6.1.7. Annually, the Contractor shall present the NVHA with a financial assessment, including detailed modeling scenarios, of each therapeutic class within the PDL, along with recommendations for preferred drugs within each reviewed category.

6.1.8. The Contractor shall provide an annual report, in a mutually agreed upon format, detailing projected cost savings and cost avoidance for each class based on preferred drug placement. These estimates shall utilize Nevada Medicaid utilization data and shall factor in current market share, federal and supplemental rebates, and the federal rebate offset. Upon request, the Contractor shall also provide pharmacy Point of Sale (POS) utilization data for specific drugs and drug classes.

6.1.9. 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.

6.1.10. The Contractor shall provide recommendations for optimizing cost avoidance or savings potential, considering the availability of generic products. The Contractor should advise the NVHA on opportunities to prefer brand-name products over generics when the net cost of the brand-name product is lower. Additionally, the Contractor shall inform the NVHA of the optimal timing for transitioning to preferred generic products when there are any market changes that affect the preferred net cost of generics.

6.1.11. The Contractor shall provide consultative advice to the NVHA on managing specialty drug costs, including recommending Point of Sale (POS) quantity limits for new and existing specialty drugs, and delivering quarterly reports on specialty spending and per-member-per-month costs based on pharmacy utilization.

6.1.12. The Contractor shall offer insights on new specialty oncology drugs, including access to oncology management experts and assistance with implementing National Comprehensive Cancer Network guidelines, while also providing quarterly updates on biosimilar products and regulatory changes.

6.1.13. The Contractor shall maintain and regularly update the PDL in a format agreed upon by both the Contractor and the NVHA. Once approved by the NVHA, the Contractor is responsible for posting a publicly accessible PDL drug lookup on a NVHA-approved website, indicating PDL coverage status and applicable utilization management criteria.

7. DUR, UM, and Care Coordination

7.1. Overview

7.1.1. The Contractor shall collaborate and support the NVHA staff in the implementation and management of the drug utilization review (DUR), utilization management (UM), and care coordination programs for all Medicaid populations. This collaboration and support shall include the Contractor actively coordinating with other contractor s to support all Nevada Medicaid populations.

7.2. Committees

7.2.1. The Contractor shall prepare for, provide recommendations for, and support NVHA staff in the coordination, attendance, logistics, online platform management, agenda development, public comment facilitation, recording, draft minutes, follow-ups, and resulting implementation needs for all current and future State pharmacy committees, ensuring compliance with Nevada Open Meeting Law and applicable bylaws. All deliverables shall be provided within a time frame defined by the NVHA. Current committees include the State's:

a. Drug Utilization Board

b. Silver State Scripts Board

c. Advisory Committee on Medicaid Innovation

d. Medicaid Reinvestment Advisory Committee

7.3. Drug Utilization Review/Silver State Scripts Board

7.3.1. The Contractor shall deliver complete and accurate draft meeting minutes within 14 days post-meeting, reflecting proceedings clearly and meeting legal requirements, with final materials approved by the NVHA before distribution.

7.3.2. The Contractor shall coordinate with the NVHA, Managed Care Organizations, and any other contractors to ensure timely, conflict-free information sharing, prepare and review meeting materials, propose quarterly topics, and respond promptly to all Medicaid drug program inquiries.

7.3.3. The Contractor shall conduct quarterly drug class reviews and provide recommendations for medications evaluated by the Silver State Script Board and other State committees and boards as needed. The reviews shall be based on evidence regarding clinical effectiveness, safety, relevant data from FDA approvals, peer-reviewed studies, and clinical guidelines. The reviews shall be updated within six months of new data and each review shall summarize the data and its sources.

7.3.4. The Contractor shall provide reviews and recommendations for new drugs, including specialty products, before the Silver State Script Board and other State committees and boards as needed.

7.3.5. The Contractor shall monitor the market and provide updates to the NVHA, including 30 days' notice for new product launches and monthly reports on new products, FDA approvals, and new generics.

7.3.6. The Contractor shall offer recommendations to control costs in high-cost therapeutic areas.

7.3.7. The Contractor shall advise the NVHA on financial impacts of CMS regulatory changes affecting the Medicaid pharmacy program.

7.3.8. The Contractor shall establish and maintain a NVHA-approved web-based document retrieval site for DUR Board members to access meeting information.

7.4. Retrospective DUR (retro DUR)

7.4.1. Primary Objective

7.4.1.1. The primary objective of retrospective drug utilization review (retro DUR) is to enhance the health outcomes of all Nevada Medicaid members through educational interventions that inform prescribers and pharmacies about potential drug-related issues. This process focuses on achieving measurable results and includes specific reporting requirements. Drug utilization review services shall encompass drugs processed through both the pharmacy benefit and those physician‐administered drugs processed through the medical benefit. At a cadence designated by the NVHA, clinically significant DUR exceptions or those that offer substantial cost savings are chosen for intervention. Following each intervention, the results and outcomes are assessed for their clinical and economic impact. The criteria used for interventions and the outcomes achieved shall comply with state and federal reporting standards.

7.4.2. Key Expectations

7.4.2.1. The Contractor, at a cadence determined by the NVHA, shall perform reviews of Medicaid claims data to identify potential drug use exceptions, prescribing or dispensing patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care among prescribers, pharmacists, and Medicaid members. The Contractor shall develop the criteria and identify practice parameters which will comprise the predetermined standards used to identify exceptions in their monthly retrospective claim analysis. Predetermined standards and minimum criteria shall be presented first to the NVHA and, if approved by the NVHA, subsequently to the DUR Board in an open meeting of the Board.