Att 11 - Submittal Form M (Part 1 of 2) - Financial Requirements.xlsx
XLSX spreadsheet 43 KB Posted
- Solicitation number
- 2025-0200-0177 / 02-101-25
- Issued by
- Alaska
About this file
This document is a Submittal Form M (Part 1 of 2) for Financial Requirements related to a Pharmacy Benefit Manager (PBM) contract opportunity for the State of Alaska. The contract is for a three-year initial period effective January 1, 2027, through December 31, 2029, with an additional six-month implementation period and eight optional one-year renewal terms solely at the State's discretion. The solicitation covers PBM services for three distinct plans: a Commercial Plan for Active Employees, a Commercial Plan for Non-EGWP Retirees, and an EGWP (Employer Group Waiver Plan) with Wrap Plan for Retirees.
The financial requirements emphasize a transparent pricing arrangement with 100% pass-through of rebates for all three plans. Key financial provisions include guaranteed PBM fees from January 1, 2027, through December 31, 2029, with pricing for the final year applicable to subsequent optional renewals. The document requires detailed confirmations on multiple aspects of financial management, including rebate handling, drug classification, specialty pharmacy programs, generic dispensing rates, and trend guarantees. Offerors must provide comprehensive pricing transparency, guarantee minimum rebate levels, ensure pass-through of all manufacturer revenues, and commit to detailed quarterly and annual financial reconciliation reporting. The State seeks a PBM solution that offers competitive pricing, full financial transparency, and comprehensive pharmacy benefit management services across its employee and retiree populations.
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Financial Requirements
| Submittal Form M - Financial Requirements (Part 1 of 2) | |||
| Financial Questionnaire | |||
| Offerors must complete all financial questions as instructed. For each of the three initial contract years, calendar year 2027-2029, offeror must provide a transparent pricing arrangement with 100% passthrough of rebates. Offeror must specify whether the offeror can comply by selecting "Confirmed" or "Not Confirmed" from the drop-down menu option in column C, or responded with a brief answer (e.g., yes, no, or a short phrase) in column D. Responses requiring a written narrative response will be provided on Submittal Form M (Part 2 of 2) – Financial Requirements Narrative Response Form. | |||
| All PBM fees must be guaranteed from January 1, 2027, through December 31, 2029. The pricing for the final year of the initial contract term, January 1, 2029, through December 31, 2029, will apply to all subsequent optional one-year renewals exercised by the State, unless updated pricing terms are negotiated by the State and executed via the contract amendment process. | |||
| Offerors are required to complete this submittal form by suppling responses to all rows. | |||
| 1.1 Term (Sec. 3.06) | Confirmation | Answer | |
| 1.1.1 | Offeror must confirm, if awarded the resulting contract from this RFP, the offeror shall provide PBM services for a three-year initial period effective January 1, 2027, through December 31, 2029. NOTE: 3.5-year initial contract term effective approximately July 1, 2026, through December 31, 2029, with eight one-year renewal options solely at the State’s discretion. Initial six months is designated as an implementation period (RFP Sec. 3.02 and 3.06). | Select One | |
| 1.1.2 | a.) Offeror must confirm their proposed pricing for the Commercial Plan (Active Employee and Non-EGWP Retiree Plans) shall go into effect on January 1, 2027, as long as the State agrees to that pricing at least 30 days prior to the effective date through a fully executed contract signed by all parties. | Select One | |
| 1.1.3 | a.) Offeror must confirm their proposed pricing for the EGWP with Wrap Plan shall go into effect on January 1, 2027, as long as the State agrees to that pricing at least 30 days prior to the effective date through a fully executed contract signed by all parties. | Select One | |
| 1.1.4 | a.) Offeror must confirm the financial guarantees for any partial contractual year that results from an early termination; regardless of whether it was with cause or without cause; shall still be guaranteed, reconciled, and the offeror shall still make payments for any shortfalls for those resulting partial contractual years with less than 12 months. | Select One | |
| b.) If not confirmed, offeror must indicate in column D what penalties, if any, shall apply. | |||
| 1.1.5 | Market Check: Offeror must confirm that they agree to a mid-contract term market check, that may be requested as soon as the second quarter of the first contract year, conducted by an independent third-party to ensure the State is receiving appropriate current pricing terms competitive within the industry based on its volume and membership for each of the three plans as described in Section 2.02 About AlaskaCare, and shall review the State’s financial terms compared to financial offering presented to similar employers in the marketplace as deemed appropriate as part of this process and offer improved pricing to the State if there is savings of 1% or more in the marketplace. The financial guarantees for any partial contractual year that results from the implementation of new pricing shall still be guaranteed, reconciled and the offeror shall still make payments for any shortfalls for those resulting partial contractual terms with less than 12 months and those contractual terms with over 12 months. | Select One | |
| 1.1.6 | Client Eligibility: Offeror confirms that all eligibility records are the sole property of the State. Selling or providing of the State’s eligibility data to ANY outside entities must be approved in advance, reported monthly, and all income derived must be disclosed and shared per agreement with the State. Even if the PBM has not 'sold' the eligibility data, it is NOT free to use the eligibility data for analyses that they publish or provide to outside industries (RFP Sec. 3.06 and 3.15). | Select One | |
| 1.1.7 | Client Claims Data: Offeror confirms that all claims data records are the sole property of the State and must be made available upon request to the State and its representatives. Selling or providing of the State’s claims data to ANY outside entities must be approved in advance, reported monthly, and all income derived must be disclosed and shared per agreement with the State. Even if PBM has not 'sold' the claims data, it is NOT free to use the claims data for analyses that they publish or provide to outside industries (RFP Sec. 3.06 and 3.15). | Select One | |
| 1.1.8 | The offeror must confirm they shall maintain all pertinent records according to CMS requirements. In the event of a contract termination, PBM will be required to cooperate and provide to either the State or a delegated State representative, all pertinent historical records to successfully transition to a new PBM. | Select One |
| 1.2 Definitions (Applies to both the Commercial and EGWP with enhanced plan design plans)(Sec. 2.03) | Confirmation | Answer | |
| 1.2.1 | 340B Claim is a claim that is identified from a pharmacy which has a 340B status code of “38” or “39” in the NCPDP DataQ database, or a claim with a claim status code of "20". Additionally, a 340B Claim could mean any other claim identified by receiving 340B program discounts, pricing, or concessions. | Select One | |
| 1.2.2 | Average Wholesale Price (AWP) is based on a date sensitive, 11-digit NDC as supplied by a nationally recognized pricing source (i.e., Medi-Span) for retail, mail order, and specialty adjudicated claims. | Select One | |
| 1.2.3 | Authorized Generic is a brand drug that is marketed without the brand name on its label. Authorized generic drugs are therapeutically equivalent to its brand drug having the same active and inactive ingredients and is included on the FDA Listing of Authorized Generics as of the dispense date of the prescription. | Select One | |
| 1.2.4 | Biosimilar is a biological product that is approved by the FDA as being highly similar to an FDA-approved biologic drug, or reference product. Biosimilar drugs have no clinically meaningful difference in safety, purity or potency when compared to the reference product. | Select One | |
| 1.2.5 | Brand Drug is a drug with a Medi-Span code of "M" (co-branded product), "N" (single-source brand) or "O" (original product) as of the dispense date of the prescription based on the NDC-11 code of the prescription. | Select One | |
| 1.2.6 | Cash Card Program is any program where members receive prescriptions through a PBM-program or third-party vendor that compares cash discounted drug prices to typical usual and customary prices and navigates the member to the lowest cost pharmacy or overrides the cost at their current pharmacy to match the lowest cost price. | Select One | |
| 1.2.7 | Exclusive Distribution Drug (EDD) is a specialty drug only available by a single specialty pharmacy provider. | Select One | |
| 1.2.8 | Generic Drug is an FDA approved drug that is pharmaceutically equivalent and interchangeable with a brand drug counterpart with an identical amount of the same active ingredient(s). Generic drugs have either a Medi-Span code of "Y" (generic) or a Medi-Span code of "N" or "O" with a DAW Code of 5 as of the dispense date of the prescription based on the NDC-11 code of the prescription. (Generic drugs include Single-Source Generics, Multi-Source Generics, Authorized Generics, generic products involved in patent litigation and House Generics.) | Select One | |
| 1.2.9 | House Generic is a drug that is submitted with a DAW code of 5. | Select One | |
| 1.2.10 | Limited Distribution Drug (LDD) is a specialty drug only available by a limited number (e.g., less than three) of specialty pharmacy providers. | Select One | |
| 1.2.11 | Maximum Allowable Cost (MAC) is the maximum allowable unit cost of a drug and establishes an upper limit reimbursement price for certain drugs dispensed without regard to the specific manufacturer whose drug is dispensed, and which drugs are identified on a “MAC List”. | Select One | |
| 1.2.12 | Members are all eligible employees and their eligible dependents enrolled under the plan’s prescription benefit program. | Select One | |
| 1.2.13 | Member Copay means members will pay the lowest of the following: Fund copay/coinsurance, Fund-negotiated discounted ingredient cost plus dispensing fee, usual and customary charges (if at retail), MAC (maximum allowable cost) or retail cash price (if at retail) at retail, mail, and specialty pharmacies. | Select One | |
| 1.2.14 | Over-the-Counter Claim (OTC) is a claim for a drug that does not require a prescription for a member to purchase and the plan has decided to include as a covered product with a prescription. OTC Claims are further defined as having an "O" or "P" in Medi-Span's Rx-OTC Indicator Code. | Select One | |
| 1.2.15 | Paid Claims are all transactions made on eligible members that result in a payment to pharmacies or members from the plan or the member copays. (Does not include reversals, rejected claims and adjustments.) Each unique prescription that results in payment shall be calculated separately as a paid claim. | Select One | |
| 1.2.16 | Pass-through Pricing is the invoicing to the plan for a specific prescription that is equal to the amount reimbursed to the pharmacy for a specific prescription on behalf of the plan by the PBM. | Select One | |
| 1.2.17 | PEPM stands for per employee or retiree per month. | Select One | |
| 1.2.18 | PMPM stands for per member per month. | Select One | |
| 1.2.19 | Pricing Channel is either retail or Retail-30 pharmacies, Retail-90 or Retail-Plus pharmacies, mail order pharmacies or the PBM's specialty pharmacy. | Select One | |
| 1.2.20 | Rebates is compensation or remuneration of any kind received or recovered from a pharmaceutical manufacturer attributable to the purchase or utilization of covered drugs by eligible persons, including, but not limited to, incentive rebates categorized as purchase discounts; credits; rebates, regardless of how categorized; market share incentives; promotional allowances; commissions; educational grants; market share of utilization; drug pull-through programs; implementation allowances; clinical detailing; rebate submission fees; and administrative or management fees. Rebates also include any fees that PBM receives from a pharmaceutical manufacturer for administrative costs, formulary placement, and/or access. | Select One | |
| 1.2.21 | Single Source Generic (SSG) is a generic drug that is only manufactured by one generic drug manufacturing company, which includes a brand drug with a Medi-Span code = "O". | Select One | |
| 1.2.22 | Specialty Drug means a drug or product used to treat complex and rare diseases and requires at least four of the following: (1) a medication used to treat complex or rate conditions; (2) injectable or infused medication; (3) a medication that requires special packaging, handling, administration and/or monitoring; (4) high cost medication; (5) a biologic medication targeting a specific part of the disease process; (6) a medication dispensed via a limited number of pharmacies. | Select One | |
| 1.2.23 | Usual and Customary (U&C) is a pharmacy's usual selling price that a cash paying customer pays for prescription drugs. | Select One | |
| 1.2.24 | Zero Balance Due (ZBD) Claim is a claim where the member pays the total amount of the discounted ingredient cost plus dispensing fee and any applicable sales tax. | Select One | |
| 1.2.25 | 100% Pass Through of Rebates means the PBM passes through 100% of ALL pharmaceutical manufacturer revenue earned to the plan and does not charge an administrative fee for this arrangement. The PBM discloses details of all other programs and services generating financial remuneration from outside entities, including manufacturers and retailers. All of this revenue is verifiable and auditable. | Select One |
| 1.3 Financial Requirements (RFP Sec. 3.06) | Confirmation | Answer | |
| 1.3.1 | Offeror must confirm their cost proposal for the Commercial Plan for Active Employees is based on a transparent pricing arrangement with 100% passthrough of rebates. | Select One | |
| 1.3.2 | Offeror must confirm their cost proposal for the Commercial Plan for Non-EGWP Retirees is based on a transparent pricing arrangement with 100% passthrough of rebates. | Select One | |
| 1.3.3 | Offeror must confirm their cost proposal for the EGWP with Wrap Plan is based on a transparent pricing arrangement with 100% passthrough of rebates. | Select One | |
| 1.3.4 | Offeror must confirm they shall, at a minimum, duplicate the plan features and levels of coverage presently offered by the State without impacting their proposed pricing. | Select One | |
| 1.3.5 | Offeror must confirm they shall provide run-out claims processing for the State of Alaska for 12 months after contract termination at no additional cost to the State. | Select One | |
| 1.3.6 | Offeror must confirm all pricing shall be effective and guaranteed for the term of the contract and shall not include adjustments for claims volume changes or claims volume shifts amongst the various provider channels (e.g., mail utilization rates decline, or 90-day retail utilization increases). | Select One | |
| 1.3.7 | Offeror must confirm all pricing shall be effective and guaranteed for the term of the contract and shall not be modified or amended if plan's membership decreases by less than 30%. | Select One | |
| 1.3.8 | Offeror must confirm all pricing shall be effective and guaranteed for the term of the contract and shall not be modified or amended if the State implements or adds a 100% member paid plan design such as a high deductible health plan/consumer-driven health plan option. | Select One | |
| 1.3.9 | Offeror must confirm they shall give notice to the State of any switch to the source of the aggregate AWP with at least a 180-day notice. Any switch must be based on a book of business decision and apply to similarly situated clients like the State. In the event that a switch is made it must be price neutral and acceptable to the State. | Select One | |
| 1.3.10 | Offeror must confirm they shall be responsible for collecting any outstanding member cost shares for prescriptions dispensed through the mail order facility. The PBM shall not invoice the State for any uncollected member cost shares even if there is a debit threshold in place (RFP Sec. 3.03). | Select One | |
| 1.3.11 | Offeror must confirm that mail order service must notify the individual member, the State or its designee prior to substituting products that shall result in higher member co-pay. | Select One | |
| 1.3.12 | Offeror must confirm they guarantee that any preferred drug, or program the offeror recommends the State to implement, shall result in a lower ingredient cost before the application of rebates on the promoted drug to both the member and the State. | Select One | |
| 1.3.13 | Offeror must confirm they shall guarantee Retail/Mail Order unit cost equalization meaning that Mail Order unit costs prior to member cost sharing, dispensing fees, and sales taxes charged shall be no greater than the unit cost for the same NDC-11 adjusted for quantity and days' supply at Retail. | Select One | |
| 1.3.14 | a.) Offeror must confirm they shall guarantee that the cost of a drug at mail shall be equal to or less than the cost of the identical drug at retail on the same day, inclusive of U&C pricing. | Select One | |
| b.) Offeror confirm that in the case that the State identifies any situation in which the State paid more for a prescription at mail than the State would have paid at retail on the same day, including U&C pricing, the offeror shall reimburse the State on a dollar-for-dollar basis. | Select One | ||
| 1.3.15 | a.) Offeror must indicate in column D how many MAC lists and MAC drug price lists the offeror maintains. | ||
| b.) If more than one, offeror must confirm they have explained how the multiple lists are used in relationship to the list(s) that shall be used for the State, within their technical proposal (Submittal Form M - Financial Requirements Narrative Response Form). | Select One | ||
| 1.3.16 | Offeror must confirm they have provided the discounts, dispensing fees, and logic associated with the compounds the offeror administers when it is clinically appropriate, within their technical proposal (Submittal Form M - Financial Requirements Narrative Response Form). | Select One | |
| 1.3.17 | Offeror must confirm that mail order and specialty drug dispensing fees shall remain constant throughout the contract term and shall not be increased for any increases in postage rates/charges, shipping, handling, or packaging (i.e., U.S. mail and/or applicable commercial courier services). | Select One | |
| 1.3.18 | Offeror must confirm mail order pricing and rebates shall apply to all claims that adjudicate at mail regardless of days' supply. | Select One | |
| 1.3.19 | Offeror must confirm Retail 30 pricing and rebates shall apply to all claims that adjudicate at the Retail 30 network with 1-30 days supply. | Select One | |
| 1.3.20 | Offeror must confirm Retail 90 pricing and rebates shall apply to all claims that adjudicate at the Retail 90 network with 31-90 days supply. | Select One | |
| 1.3.21 | Offeror must confirm specialty pricing and rebates shall apply to all claims that adjudicate at the offeror's specialty pharmacy regardless of days' supply. | Select One | |
| 1.3.22 | Offeror must confirm the applicable specialty pricing and rebates shall apply to all claims that adjudicate at participating retail pharmacies under the respective specialty pharmacy program regardless of days' supply. | Select One | |
| 1.3.23 | Offeror must confirm the proposed pricing is not part of a coalition pricing arrangement. | Select One | |
| 1.3.24 | Offeror must confirm products subject to patent actions are not excluded from the financial discount, dispensing fee, and rebate guarantees. | Select One | |
| 1.3.25 | Offeror must confirm they shall not bill for medical supplies and services in the dispensing/usage of specialty medications not covered by the State's prescription drug plan. | Select One | |
| 1.3.26 | Offeror must confirm they guarantee that the percentage increase in the Generic Drug Ingredient Cost compared on a contract year basis with the immediately prior contract year shall be no greater than 2% throughout the term of the contract. This trend calculation mustl be based on the discounted cost plus dispensing fees and after rebates. Trend calculations must not include member cost share. | Select One | |
| Pricing Guarantee Reconciliation (RFP Sec. 3.06) | |||
| 1.3.27 | Offeror must confirm each distinct non-rebate pricing guarantee (including discounts and dispensing fees) shall be measured and reconciled on a component (e.g. retail brand, retail generic, retail 90 brand, retail 90 generic, mail order brand, mail order generic, specialty drugs at participating retail pharmacies, and specialty drugs at the PBM's Specialty Pharmacy, limited distribution drugs at participating pharmacies that are not the PBM's Specialty Pharmacy, limited distribution drugs at the PBM's Specialty Pharmacy) basis only and guaranteed on a dollar-for-dollar basis with 100% of any shortfalls recouped by the State. Surpluses in one component (including rebates) may not be utilized to offset deficits in another component (e.g. retail brand, retail generic, retail 90 brand, retail 90 generic, mail order brand, mail order generic, specialty drugs at participating retail pharmacies, and specialty drugs at the PBM's Specialty Pharmacy, limited distribution drugs at participating pharmacies that are not the PBM's Specialty Pharmacy, limited distribution drugs at the PBM's Specialty Pharmacy). | Select One | |
| 1.3.28 | Offeror must confirm their Retail 30 network guarantees and Retail 90 network guarantees are measured and reconciled on a separate component basis given that they have separate guaranteed rates. A surplus for either of these guarantees must not be used to offset a shortfall for one of the other retail components or any other component guarantees. | Select One | |
| 1.3.29 | Offeror must confirm that any shortfall between the actual result and the guarantee shall be paid, dollar-for-dollar, to the State within 90 days of the end of each contractual year for both the commercial and EGWP with enhanced plan design contracts. | Select One | |
| 1.3.30 | Offeror must confirm that any shortfall amount between the actual result and the guarantee that is not paid, dollar-for-dollar, to the State within the agreed upon time frame after the end of each contractual year shall accrue a pro-rated 2% monthly late fee of each contractual year. | Select One | |
| 1.3.31 | Offeror must confirm their Commercial and EGWP with enhanced plan design drug spend shall not be reconciled in aggregate for purposes of the guarantee terms. | Select One | |
| 1.3.32 | Brand and Generic Discount Guarantee Calculations | ||
| a.) Offeror must confirm that their Minimum Brand and Minimum Generic Discount Guarantees for retail, mail, and specialty shall be defined and calculated as follows: (1-Aggregate Ingredient Cost/Aggregate AWP). | Select One | ||
| b.) Offeror must confirm their Aggregate Ingredient Cost prior to the application of the plan specific member cost share (including member paid penalties) shall be the basis of the financial guarantee calculation. | Select One | ||
| c.) Offeror must confirm that all AWP discount guarantees are calculated using the date sensitive AWP based on the 11-digit NDC of the actual product and actual package size that is dispensed. | Select One | ||
| d.) Offeror must confirm Dispensing Fees are not included in their Aggregate Ingredient Cost. | Select One | ||
| e.) Offeror must confirm their guarantee reconciliation shall not be limited to net cost claims. Zero balance due claims or zero amount claims shall be included in the guaranteed measurement for AWP, ingredient cost, achieved discounts or dispensing fee calculations at the discounted cost before copay. | Select One | ||
| f.) Offeror must confirm both the Aggregate Ingredient Cost and Aggregate AWP from the actual date of claim adjudication shall be used. | Select One | ||
| g.) Offeror must confirm any penalty amounts paid by the member as a result of the DAW 1 or 2 penalty program shall not be used by the offeror in discount guarantee reconciliations. | Select One | ||
| h.) Offeror must confirm their guarantee measurement excludes the savings impact from drug utilization review (DUR) programs, formulary programs, utilization management programs, and/or other therapeutic interventions. | Select One | ||
| i.) Offeror must confirm all of their proposed discount guarantees are on a minimum guaranteed basis (i.e., not a flat, fixed, or locked basis) and any discount achieved beyond the minimum guarantee shall be passed on to the State. | Select One | ||
| j.) Offeror must confirm they have provided a complete listing of all proposed exclusions to the offeror's proposed brand and generic discount guarantees, within their technical propsoal (Submittal Form M - Financial Requirements Narrative Response Form). | Select One | ||
| 1.3.33 | Brand and Generic Dispensing Fee Guarantee Calculations | ||
| a.) Offeror must confirm their Average Dispensing Fee Guarantees for retail, mail, and specialty shall be defined and calculated as follows: (Total Dispensing Fees/Total Number of Prescriptions). | Select One | ||
| b.) Offeror must confirm their dispensing fee guarantees does not exclude any prescription adjudicated by the offeror under the plan of benefits from either the numerator (dispensing fees) or the denominator (prescription count or claim count) of the guarantee reconciliation calculation detailed above in item 1.3.33. | Select One | ||
| c.) Offeror must confirm all their proposed dispensing fee guarantees are on a maximum guaranteed basis. | Select One | ||
| 1.3.34 | Active Employee Plan: The following list of drugs and/or products are the only drugs and/or products that are allowed to be excluded from the AWP discounts and dispensing fees guarantees. Offerors and the selected PBM must structure their underwriting to account for only those drug and/or product exclusions. Offerors must indicate in Column D if the following products are included or excluded from their acceptable exclusions for the proposed discount and dispensing fee guarantees. | ||
| a.) Compounds | Select One | ||
| b.) Out-of-Network Claims | Select One | ||
| c.) Paper/Member Submitted Claims | Select One | ||
| d.) Secondary Payor/COB/Subrogation Claims | Select One | ||
| e.) Indian Health Services and Tribal Claims | Select One | ||
| f.) Veteran Administrative Claims | Select One | ||
| 1.3.35 | Non-EGWP Retiree Plan: The following list of drugs and/or products are the only drugs and/or products that are allowed to be excluded from the AWP discounts and dispensing fees guarantees. Offerors and the selected PBM must structure their underwriting to account for only those drug and/or product exclusions. Offerors must indicate in Column D if the following products are included or excluded from their acceptable exclusions for the proposed discount and dispensing fee guarantees. | ||
| a.) Compounds | Select One | ||
| b.) Out-of-Network Claims | Select One | ||
| c.) Paper/Member Submitted Claims | Select One | ||
| d.) Secondary Payor/COB/Subrogation Claims | Select One | ||
| e.) Indian Health Services and Tribal Claims | Select One | ||
| f.) Veteran Administrative Claims | Select One | ||
| 1.3.36 | EGWP/Wrap Retiree Plan: The following list of drugs and/or products are the only drugs and/or products that are allowed to be excluded from the AWP discounts and dispensing fees guarantees. Offeror and the selected PBM must structure their underwriting to account for only those drug and/or product exclusions. Offeror must indicate in Column D if the following products are included or excluded from their acceptable exclusions for the proposed discount and dispensing fee guarantees. | ||
| a.) Compounds | Select One | ||
| b.) Out-of-Network Claims | Select One | ||
| c.) Paper/Member Submitted Claims | Select One | ||
| d.) Secondary Payor/COB/Subrogation Claims | Select One | ||
| e.) Indian Health Services and Tribal Claims | Select One | ||
| f.) Veteran Administrative Claims | Select One | ||
| 1.3.37 | Active Employee Plan: The following list of drugs and/or products are required inclusions in the discounts and dispensing fees guarantees. If offeror excludes any of these categories or other categories of drugs and/or products listed below, offeror's proposal may be disqualified. Offeror must confirm in Column D the following products are included in their proposed discount and dispensing fee guarantees: | ||
| a.) 340B Pharmacy Claims | Select One | ||
| b.) Vaccines (non-COVID) | Select One | ||
| c.) Vaccines (COVID) | Select One | ||
| d.) Over the Counter (OTC) Products as defined by Medispan | Select One | ||
| e.) Diabetic Test Strips | Select One | ||
| f.) Continuous Glucose Monitors (CGM)/CGM Sensors | Select One | ||
| g.) Insulins | Select One | ||
| h.) Prescription Vitamins, Smoking Cessation Products and Contraceptives | Select One | ||
| i.) Ancillary Supplies defined by Medispan AHFS Code 940000 | Select One | ||
| j.) Non-Drug Claims | Select One | ||
| k.) New-to-Market | Select One | ||
| l.) Limited Distribution Drugs (LDD) | Select One | ||
| m.) Exclusive Distribution Drugs (EDD) | Select One | ||
| n.) Low-WAC biosimilars | Select One | ||
| o.) High-WAC biosimilars | Select One | ||
| p.) Long Term Care (LTC) Pharmacy Claims | Select One | ||
| q.) Home Infusion | Select One | ||
| r.) DAW 1 processed claims | Select One | ||
| s.) DAW 2 processed claims | Select One | ||
| t.) DAW 5 processed claims | Select One | ||
| u.) DAW 0, 3, 4, 6, 7, 8 and 9 processed claims | Select One | ||
| v.) Products subject to patent actions | Select One | ||
| w.) Multi-source brand claims | Select One | ||
| x.) Drugs not approved by the Food and Drug Administration (FDA) | Select One | ||
| y.) Multi-source Brand (MSB) claims | Select One | ||
| z.) Zero-balance due (ZBD) claims | Select One | ||
| aa.) Claims from all 50 states and the District of Columbia | Select One | ||
| 1.3.38 | Non-EGWP Retiree Plan: The following list of drugs and/or products are required inclusions in the discounts and dispensing fees guarantees. If offeror excludes any of these categories or other categories of drugs and/or products listed below, offeor's proposal may be disqualified. Offeror must confirm in Column D the following products are included in their proposed discount and dispensing fee guarantees: | ||
| a.) 340B Pharmacy Claims | Select One | ||
| b.) Vaccines (non-COVID) | Select One | ||
| c.) Vaccines (COVID) | Select One | ||
| d.) Over the Counter (OTC) Products as defined by Medispan | Select One | ||
| e.) Diabetic Test Strips | Select One | ||
| f.) Continuous Glucose Monitors (CGM)/CGM Sensors | Select One | ||
| g.) Insulins | Select One | ||
| h.) Prescription Vitamins, Smoking Cessation Products and Contraceptives | Select One | ||
| i.) Ancillary Supplies defined by Medispan AHFS Code 940000 | Select One | ||
| j.) Non-Drug Claims | Select One | ||
| k.) New-to-Market | Select One | ||
| l.) Limited Distribution Drugs (LDD) | Select One | ||
| m.) Exclusive Distribution Drugs (EDD) | Select One | ||
| n.) Low-WAC biosimilars | Select One | ||
| o.) High-WAC biosimilars | Select One | ||
| p.) Long Term Care (LTC) Pharmacy Claims | Select One | ||
| q.) Home Infusion | Select One | ||
| r.) DAW 1 processed claims | Select One | ||
| s.) DAW 2 processed claims | Select One | ||
| t.) DAW 5 processed claims | Select One | ||
| u.) DAW 0, 3, 4, 6, 7, 8 and 9 processed claims | Select One | ||
| v.) Products subject to patent actions | Select One | ||
| w.) Multi-source brand claims | Select One | ||
| x.) Drugs not approved by the Food and Drug Administration (FDA) | Select One | ||
| y.) Multi-source Brand (MSB) claims | Select One | ||
| z.) Zero-balance due (ZBD) claims | Select One | ||
| aa.) Claims from all 50 states and the District of Columbia | Select One | ||
| 1.3.39 | EGWP/Wrap Retiree Plan: The following list of drugs and/or products are required inclusions in the discounts and dispensing fees guarantees. If offeror excludes any of these categories or other categories of drugs and/or products listed below, offeror's proposal may be disqualified. Offeror must confirm in Column D the following products are included in their proposed discount and dispensing fee guarantees: | ||
| a.) 340B Pharmacy Claims | Select One | ||
| b.) Vaccines (non-COVID) | Select One | ||
| c.) Vaccines (COVID) | Select One | ||
| d.) Over the Counter (OTC) Products as defined by Medispan | Select One | ||
| e.) Diabetic Test Strips | Select One | ||
| f.) Continuous Glucose Monitors (CGM)/CGM Sensors | Select One | ||
| g.) Insulins | Select One | ||
| h.) Prescription Vitamins, Smoking Cessation Products and Contraceptives | Select One | ||
| i.) Ancillary Supplies defined by Medispan AHFS Code 940000 | Select One | ||
| j.) Non-Drug Claims | Select One | ||
| k.) New-to-Market | Select One | ||
| l.) Limited Distribution Drugs (LDD) | Select One | ||
| m.) Exclusive Distribution Drugs (EDD) | Select One | ||
| n.) Low-WAC biosimilars | Select One | ||
| o.) High-WAC biosimilars | Select One | ||
| p.) Long Term Care (LTC) Pharmacy Claims | Select One | ||
| q.) Home Infusion | Select One | ||
| r.) DAW 1 processed claims | Select One | ||
| s.) DAW 2 processed claims | Select One | ||
| t.) DAW 5 processed claims | Select One | ||
| u.) DAW 0, 3, 4, 6, 7, 8 and 9 processed claims | Select One | ||
| v.) Products subject to patent actions | Select One | ||
| w.) Multi-source brand claims | Select One | ||
| x.) Drugs not approved by the Food and Drug Administration (FDA) | Select One | ||
| y.) Multi-source Brand (MSB) claims | Select One | ||
| z.) Zero-balance due (ZBD) claims | Select One | ||
| aa.) Claims from all 50 states and the District of Columbia | Select One | ||
| Administration Fees (RFP Sec. 3.06) | |||
| 1.3.40 | Offeror must confirm there are NO additional fees (beyond those outlined in the Financial Proposal Section) required to administer the services outlined in this RFP. Any mandatory fees, including clinical and formulary program fees, must be clearly outlined in the Financial Proposal Section. | Select One | |
| 1.3.41 | Offeror must confirm there are NO additional fees to coordinate the deductible and the maximum out of pocket with the medical carrier. | Select One | |
| 1.3.42 | Offeror must confirm they shall credit the State the cost difference for any claims in which the State was considered “primary” for the claim, but the claim should have been considered “secondary” for the State (e.g., workers' compensation claim). | Select One | |
| 1.3.43 | a.) Offeror must confirm all data related services are included under their base administrative fees, including ad hoc reporting, electronic claims files, plan design options, custom mailings, etc. | Select One | |
| b.) In addition, offeror must confirm they have detailed any data-related service fees not included in their base administrative fees, within their technical proposal (Submittal Form M - Financial Requirements Narrative Response Form). | Select One | ||
| 1.3.44 | Offeror must confirm that postage rates/charges, shipping, handling, or packaging is included in all mail order prescriptions and any mailings for the duration of the contract. | Select One | |
| 1.3.45 | Offeror must confirm that quoted fees include postage rates/charges, shipping, handling, or packaging for mail order envelopes for member prescription submission for the duration of the contract. | Select One | |
| 1.3.46 | Offeror must confirm they agree to absorb any programming or other administrative costs to meet any existing or future requirements of the Affordable Care Act. | Select One | |
| 1.3.47 | a.) Offeror must indicate in column D if there shall be any additional charges if plans/benefits are restructured or new classes of eligible members are added? | Select One | |
| b.) If so, the offeror must confirm they detailed how these additional charges are determined and what is the additional charge, within their technical proposal (Submittal Form M - Financial Requirements Narrative Response Form). | Select One | ||
| 1.3.48 | Offeror must confirm they shall only charge a fee (e.g., administrative fee or dispensing fee) for Paid Claims and shall not charge a fee for reversals, rejected claims, adjustments, or reprocessed claims. | Select One | |
| 1.3.49 | Offeror must confirm that all applicable fees include the cost of claims incurred/filled during the effective dates of this contract regardless of when the claims are actually processed and paid (run-out). | Select One | |
| Reporting (RFP Sec. 3.06) | |||
| 1.3.50 | Offeror must confirm they will provide a financial reconciliation report within 90 days after the end of each contractual year, and the report will include the contractual and actual discounts and dispensing fees for each component (e.g. retail brand, retail generic, retail 90 brand, retail 90 generic, mail order brand, mail order generic, specialty drugs at participating retail pharmacies, specialty drugs at the PBM's Specialty Pharmacy, limited distribution drugs at participating pharmacies that are not the offeror's Specialty Pharmacy, and limited distribution drugs at the PBM's Specialty Pharmacy). | Select One | |
| 1.3.51 | Offeror must confirm they have provided how the offeror will be able to proactively provide analytical reports throughout the contract year, within their technical proposal (Submittal Form M - Financial Requirements Narrative Response Form), (i.e., monthly, quarterly, semi-annually) indicating the actual performance versus the financial guarantees without a formal audit. This is in addition to the annual reconciliation reports that the offeror is expected to proactively provide to the State of Alaska. | Select One | |
| 1.3.52 | Offeror must confirm they will provide a financial rebate reconciliation report within 180 days after the end of each contractual year, and the report will include the contractual and actual rebates received by the PBM for each component (e.g. retail brand, retail 90 brand, mail order brand, specialty drugs at participating retail pharmacies and specialty drugs at the PBM's Specialty Pharmacy). | Select One | |
| 1.3.53 | Offeror must confirm they will provide quarterly utilization reports which compare the current period to the prior period on a plan year-to-date basis. Reporting must include AWP, ingredient cost, dispensing fee and rebate metrics in the aggregate and on a PMPM basis. The reporting should also provide a breakdown of brand vs. generic, retail vs. mail, and specialty vs. non-specialty. In addition, offeror confirms reports will provide a breakdown of cost and utilization by plan offering (i.e. HDHP, PPO, POS, EPO, etc). | Select One | |
| 1.3.54 | Offeror confirms they will provide weekly and/or monthly data transmissions (may include feeds to data warehouses) to at least 10 chosen vendors at no charge and two additional full, annual electronic claims files, in NCPDP format, at no charge as needed and requested by the State. In addition, offeror confirms they will also interact/exchange data with all vendors as needed at no additional charge. | Select One | |
| Rebates (RFP Sec. 3.06) | |||
| 1.3.55 | 100% Pass Through of Rebates: Offeror must confirm they agree to pass through 100% of ALL pharmaceutical manufacturer revenue earned to the Commercial Plan and shall not charge an administrative fee for this arrangement. Offeror also agrees to disclose details of all other programs and services generating financial remuneration from outside entities, including manufacturers and retailers. Offeror confirms all this revenue shall be verifiable and auditable. | Select One | |
| 1.3.56 | Offeror must confirm they shall pass through 100% of Manufacturer Administrative Fees paid by manufacturers to the offeror in relation to the Commercial Plan’s non-specialty, specialty, and overall utilization. | Select One | |
| 1.3.57 | Offeror must confirm they shall pass through 100% of Inflation Protection Payments paid by pharmaceutical manufacturers to the offeror in relation to the Commercial Plan’s utilization. | Select One | |
| 1.3.58 | For the Commercial Plan, offeror must confirm they shall pass through 100% of rebates invoiced and collected from pharmaceutical manufacturers/rebate aggregators for excluded products that are not included in the rebate and financial guarantee calculations. | Select One | |
| 1.3.59 | 100% Pass Through of Rebates: Offeror must confirm they agree to pass through 100% of ALL pharmaceutical manufacturer revenue earned to the EGWP Plan and shall not charge an administrative fee for this arrangement. The offeror agrees to disclose details of all other programs and services generating financial remuneration from outside entities, including manufacturers and retailers. The offeror confirms all of this revenue shall be verifiable and auditable. | Select One | |
| 1.3.60 | Offeror must confirm they shall pass through 100% of Manufacturer Administrative Fees paid by manufacturers to the offeror in relation to the EGWP Plan’s non-specialty, specialty, and overall utilization. | Select One | |
| 1.3.61 | Offeror must confirm they shall pass through 100% of Inflation Protection Payments paid by pharmaceutical manufacturers to the offeror in relation to the EGWP Plan’s utilization. | Select One | |
| 1.3.62 | For the EGWP plan, offeror confirms they shall pass through 100% of rebates invoiced and collected from pharmaceutical manufacturers/rebate aggregators for excluded products that are not included in the rebate and financial guarantee calculations. | Select One | |
| 1.3.63 | Offeror must confirm that each distinct rebate guarantee shall be measured and reconciled on a component (e.g. retail brand, retail 90 brand, mail order brand, specialty drugs at participating retail pharmacies, specialty drugs at the PBM's Specialty Pharmacy, limited distribution brand drugs at participating pharmacies that are not the PBM's Specialty Pharmacy, limited distribution brand drugs at the PBM's Specialty Pharmacy) basis only and guaranteed on a dollar-for-dollar basis with 100% of any shortfalls recouped by the State. Surpluses in one rebate component may only be utilized to offset deficits in another rebate component. Rebates surpluses shall not be utilized to offset deficits in any other non-rebate guaranteed component. | Select One | |
| 1.3.64 | a.) Offeror must indicate in column D if they use an external organization for rebate aggregation. | Select One | |
| b.) If so, offeror must list in column D the name of the external organization used for rebate aggregation. | |||
| 1.3.65 | a.) Offeror must confirm their Minimum Guaranteed Rebates shall apply to all brand prescriptions claims dispensed and not conditioned upon formulary status. | Select One | |
| b.) Offeror must confirm their Minimum Guaranteed Rebates shall apply to all brand prescriptions claims dispensed and not limited to only those products for which the PBM receives a rebate. | Select One | ||
| 1.3.66 | Offeror must confirm that all rebates are guaranteed on a minimum (i.e., not fixed or flat) basis, and the offeror shall pass through 100% of the rebates, including non-specialty and specialty, from all pharmaceutical manufacturer revenue that the offeror has received that is attributable to the Commercial Plan. | Select One | |
| 1.3.67 | Offeror must confirm any rebates derived from House Generics or DAW 5 claims shall be passed through at 100% to the Commercial Plan. | Select One | |
| 1.3.68 | Offeror must confirm that all rebates are guaranteed on a minimum (i.e., not fixed or flat) basis, and the offeror shall pass through 100% of the rebates, including non-specialty and specialty, from all pharmaceutical manufacturer revenue that the offeror has received that is attributable to the EGWP Plan. | Select One | |
| 1.3.69 | Offeror must confirm any rebates derived from House Generics or DAW 5 claims shall be passed through at 100% to the EGWP Plan. | Select One | |
| 1.3.70 | a.) Offeror must confirm that within 90 days after the end of each calendar quarter, the offeror shall pay quarterly rebate payments based on the minimum rebate guarantees times the brand prescriptions dispensed in the prior quarter for each respective channel (i.e., rebate payment will shall limited to the amount of rebates collected). | Select One | |
| b.) In addition to the minimimum guaranteed rebates earned in the prior quarter, offeror must confirm they shall remit to the plan all rebates received by the offeror during the prior quarter that are in excess of the minimum guarantees paid for prior quarters. | Select One | ||
| c.) Offeror must confirm that lag rebates shall continue to be paid to the State throughout the term of the contract until 100% of all earned rebates are paid even after all of the minimum rebate guarantees have been paid. | Select One | ||
| 1.3.71 | Offeror must confirm that within 90 days after the end of each calendar quarter, the offeror shall provide a detailed rebate activity Excel report listing the number of brand scripts dispensed per delivery channel, the minimum per brand script rebate amount at each delivery channel, the calculated minimum guaranteed rebate payment per delivery channel owed to the State as well as the actual year-to-date rebates received by the offeror from pharma. | Select One | |
| 1.3.72 | a.) Offeror must confirm they shall provide the annual rebate reconciliation report within 180 days of the end of each contract year. | Select One | |
| b.)Offeror must confirm that any shortfall between rebates paid-to-date, minimum guaranteed rebates and actual rebates received by the offeror for the State's utilization shalll be paid, dollar-for-dollar, to the State within 90 days of the end of the contract year. | Select One | ||
| 1.3.73 | Offeror must confirm all rebate revenue earned by the State shall be paid to the State regardless of their termination status as a client. Lag rebates on claims incurred prior to the termination date will continue to be paid to the State after termination until 100% of earned rebates are paid. | Select One | |
| 1.3.74 | Offeror must confirm rebates are paid on Wrap (Enhanced Benefit/ Supplemental Plan) claims and are included in the rebate guarantees proposed for the EGWP population. | Select One | |
| 1.3.75 | Active Employee Plan: The following list of drugs and/or products are the only drugs and/or products that are allowed to be excluded from the rebate guarantees. Offerors and the selected PBM must structure their underwriting to account for only those drug and/or product exclusions. Offeror must indicate in Column D if the following products are included or excluded from their acceptable exclusions for the proposed rebate guarantees. | ||
| a.) Compounds | Included | ||
| b.) Out-of-Network Claims | Select One | ||
| c.) Paper/Member Submitted Claims | Select One | ||
| d.) Secondary Payor/COB/Subrogation Claims | Select One | ||
| e.) Indian Health Services and Tribal Claims | Select One | ||
| f.) Veteran Administrative Claims | Select One | ||
| 1.3.76 | Non-EGWP Retiree Plan: The following list of drugs and/or products are the only drugs and/or products that are allowed to be excluded from the rebate guarantees. Offerors and the selected PBM must structure their underwriting to account for only those drug and/or product exclusions. Offeror must indicate in Column D if the following products are included or excluded from their acceptable exclusions for the proposed rebate guarantees. | ||
| a.) Compounds | Select One | ||
| b.) Out-of-Network Claims | Select One | ||
| c.) Paper/Member Submitted Claims | Select One | ||
| d.) Secondary Payor/COB/Subrogation Claims | Select One | ||
| e.) Indian Health Services and Tribal Claims | Select One | ||
| f.) Veteran Administrative Claims | Select One | ||
| 1.3.77 | EGWP/Wrap Retiree Plan: The following list of drugs and/or products are the only drugs and/or products that are allowed to be excluded from the rebate guarantees. Offerors and the selected PBM must structure their underwriting to account for only those drug and/or product exclusions. Offeror must indicate in Column D if the following products are included or excluded from their acceptable exclusions for the proposed rebate guarantees. | ||
| a.) Compounds | Select One | ||
| b.) Out-of-Network Claims | Select One | ||
| c.) Paper/Member Submitted Claims | Select One | ||
| d.) Secondary Payor/COB/Subrogation Claims | Select One | ||
| e.) Indian Health Services and Tribal Claims | Select One | ||
| f.) Veteran Administrative Claims | Select One | ||
| 1.3.78 | Active Employee Plan: The following list of drugs and/or products are required inclusions in the rebate guarantees. The selected PBM may not exclude any other drugs and/or products throughout the life of the contract. If offeror excludes any of these categories or other categories of drugs and/or products listed below, offeror's proposal may be disqualified. Offeror must confirm the following products are included in their proposed rebate guarantees: | ||
| a.) 340B Pharmacy Claims | Select One | ||
| b.) Vaccines (non-COVID) | Select One | ||
| c.) Vaccines (COVID) | Select One | ||
| d.) Over the Counter (OTC) Products as defined by Medispan | Select One | ||
| e.) Diabetic Test Strips | Select One | ||
| f.) Continuous Glucose Monitors (CGM)/CGM Sensors | Select One | ||
| g.) Insulins | Select One | ||
| h.) Prescription Vitamins, Smoking Cessation Products and Contraceptives | Select One | ||
| i.) Ancillary Supplies defined by Medispan AHFS Code 940000 | Select One | ||
| j.) Non-Drug Claims | Select One | ||
| k.) New-to-Market | Select One | ||
| l.) Limited Distribution Drugs (LDD) | Select One | ||
| m.) Exclusive Distribution Drugs (EDD) | Select One | ||
| n.) Low-WAC biosimilars | Select One | ||
| o.) High-WAC biosimilars | Select One | ||
| p.) Long Term Care (LTC) Pharmacy Claims | Select One | ||
| q.) Home Infusion | Select One | ||
| r.) DAW 1 processed claims | Select One | ||
| s.) DAW 2 processed claims | Select One | ||
| t.) DAW 5 processed claims | Select One | ||
| u.) DAW 0, 3, 4, 6, 7, 8 and 9 processed claims | Select One | ||
| v.) Products subject to patent actions | Select One | ||
| w.) Multi-source brand claims | Select One | ||
| x.) Drugs not approved by the Food and Drug Administration (FDA) | Select One | ||
| y.) Multi-source Brand (MSB) claims | Select One | ||
| z.) Zero-balance due (ZBD) claims | Select One | ||
| aa.) Claims from all 50 states and the District of Columbia | Select One | ||
| 1.3.79 | Non-EGWP Retiree Plan: The following list of drugs and/or products are required inclusions in the rebate guarantees. The selected PBM may not exclude any other drugs and/or products throughout the life of the contract. If offeror excludes any of these categories or other categories of drugs and/or products listed below, offeror's proposal may be disqualified. Offeror must confirm the following products are included in their proposed rebate guarantees: | ||
| a.) 340B Pharmacy Claims | Select One | ||
| b.) Vaccines (non-COVID) | Select One | ||
| c.) Vaccines (COVID) | Select One | ||
| d.) Over the Counter (OTC) Products as defined by Medispan | Select One | ||
| e.) Diabetic Test Strips | Select One | ||
| f.) Continuous Glucose Monitors (CGM)/CGM Sensors | Select One | ||
| g.) Insulins | Select One | ||
| h.) Prescription Vitamins, Smoking Cessation Products and Contraceptives | Select One | ||
| i.) Ancillary Supplies defined by Medispan AHFS Code 940000 | Select One | ||
| j.) Non-Drug Claims | Select One | ||
| k.) New-to-Market | Select One | ||
| l.) Limited Distribution Drugs (LDD) | Select One | ||
| m.) Exclusive Distribution Drugs (EDD) | Select One | ||
| n.) Low-WAC biosimilars | Select One | ||
| o.) High-WAC biosimilars | Select One | ||
| p.) Long Term Care (LTC) Pharmacy Claims | Select One | ||
| q.) Home Infusion | Select One | ||
| r.) DAW 1 processed claims | Select One | ||
| s.) DAW 2 processed claims | Select One | ||
| t.) DAW 5 processed claims | Select One | ||
| u.) DAW 0, 3, 4, 6, 7, 8 and 9 processed claims | Select One | ||
| v.) Products subject to patent actions | Select One | ||
| w.) Multi-source brand claims | Select One | ||
| x.) Drugs not approved by the Food and Drug Administration (FDA) | Select One | ||
| y.) Multi-source Brand (MSB) claims | Select One | ||
| z.) Zero-balance due (ZBD) claims | Select One | ||
| aa.) Claims from all 50 states and the District of Columbia | Select One | ||
| 1.3.80 | EGWP/Wrap Retiree Plan: The following list of drugs and/or products are required inclusions in the rebate guarantees. The selected PBM may not exclude any other drugs and/or products throughout the life of the contract. If offeror excludes any of these categories or other categories of drugs and/or products listed below, offeror's proposal may be disqualified. Offeror must confirm in Column D the following products are included in their proposed rebate guarantees: | ||
| a.) 340B Pharmacy Claims | Select One | ||
| b.) Vaccines (non-COVID) | Select One | ||
| c.) Vaccines (COVID) | Select One | ||
| d.) Over the Counter (OTC) Products as defined by Medispan | Select One | ||
| e.) Diabetic Test Strips | Select One | ||
| f.) Continuous Glucose Monitors (CGM)/CGM Sensors | Select One | ||
| g.) Insulins | Select One | ||
| h.) Prescription Vitamins, Smoking Cessation Products and Contraceptives | Select One | ||
| i.) Ancillary Supplies defined by Medispan AHFS Code 940000 | Select One | ||
| j.) Non-Drug Claims | Select One | ||
| k.) New-to-Market | Select One |
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