Att 4 - Submittal Form G (Part 1 of 2) - Contractual Reqs.xlsx
XLSX spreadsheet 373 KB Posted
- Solicitation number
- 2025-0200-0177 / 02-101-25
- Issued by
- Alaska
About this file
The document is a comprehensive Submittal Form G for a Pharmacy Benefit Management (PBM) contract opportunity for AlaskaCare, covering active employees, non-EGWP retirees, and Employer Group Waiver Plan (EGWP) retirees. The solicitation requires detailed responses across 14 spreadsheet tabs, addressing formulary management, clinical programs, retail network management, copay assistance, audit rights, implementation, member services, legal responsibilities, and compliance with federal regulations like the No Surprises Act. The contract appears to be seeking a comprehensive PBM solution with multiple plan design options, to be implemented for a multi-year term starting January 1, 2026.
The submission requires extensive pricing information, including AWP discounts, rebate guarantees, specialty drug pricing, and clinical program cost projections. Offerors must provide detailed formulary lists, including preferred drug lists, specialty drug lists, and excluded drug lists for each plan segment. The document emphasizes transparency, with requirements for network access, audit rights, member communications, and compliance with Medicare Part D regulations. Key financial components include performance guarantees, rebate mechanisms, and comprehensive reporting requirements, with a focus on cost management, member impact, and regulatory compliance across commercial and Medicare plan designs.
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1) Admin Requirements
| Submittal Form G - Contractual Requirements (Part 1 of 2) | |||
| The following contractual requirements must be confirmed in column C, or responded to 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 G (Part 2 of 2) – Contractual Requirements Narrative Response Form. | |||
| Offerors are required to complete this submittal form by suppling responses to all rows included on 14 spreadsheet tabs. | |||
| 1.1. Formulary Management (RFP Sec. 3.05) | Confirmation | Answer | |
| 1.1.1 | Offeror must confirm all Pricing Guarantees in the offeror's proposal are based on the PBM's lowest net cost formulary or preferred drug listing, which includes the offeror's standard drug coverage exclusions. | Select One | |
| 1.1.2 | a.) Offerors must provide the name of the Formulary they are proposing for the active employee population's Commercial Plan and the number of drug exclusions. | ||
| b.) In tab two, titled PDL Employee, offeror must provide a list of each drug by NDC, Drug Name and Therapeutic Class. | Select One | ||
| 1.1.3 | a.) Offeror must provide the name of the Specialty Formulary they are proposing for the active employee population's Commercial Plan and the number of drug exclusions, if applicable. | ||
| b.) In tab three, titled Spec Drug List Employee, offeror must provide a list of each specialty drug by NDC, Drug Name and Therapeutic Class. | Select One | ||
| 1.1.4 | In tab four, titled Excluded Drug List Employee, offeror must provide a list of the excluded non-specialty and specialty drugs and the therapeutic alternatives for the active employee population's Commercial Plan. | Select One | |
| 1.1.5 | a.) Offeror must provide the name of the Formulary they are proposing for the Non-EGWP Retiree's Commercial Plan and the number of drug exclusions in column D. | ||
| b.) In tab seven, titled PDL NonEGWP, provide a list of each drug by NDC, Drug Name and Therapeutic Class. | Select One | ||
| 1.1.6 | a.) Offer must provide the name of the Specialty Formulary they are proposing for the non-EGWP Retiree's Commercial Plan and the number of drug exclusions, if applicable, in column D. | ||
| b.) In tab eight, titled Spec Drug List NonEGWP, offeror must provide a list of each specialty drug by NDC, Drug Name and Therapeutic Class. | Select One | ||
| 1.1.7 | In tab nine, titled Excluded Drug List NonEGWP, offeror must provide a list of the excluded non-specialty and specialty drugs and the therapeutic alternatives for the Non-EGWP Retiree's commercial plan. | Select One | |
| 1.1.8 | a.) Offeror must provide the name of the Formulary they are proposing for the EGWP plan and the number of drug exclusions in column D. | ||
| b.) In tab 11, titled PDL EGWP, offeror must provide a list of each drug by NDC, Drug Name and Therapeutic Class. | Select One | ||
| 1.1.9 | a.) Offeror must provide the name of the Specialty Formulary they are proposing for the EGWP plan and the number of drug exclusions, if applicable, in column D. | ||
| b.) In tab 12, titled Spec Drug List EGWP, offeror must provide a list of each specialty drug by NDC, Drug Name and Therapeutic Class. | Select One | ||
| 1.1.10 | In tab 13, titled Excluded Drug List EGWP, offeror must provide a list of the excluded non-specialty and specialty drugs and the therapeutic alternatives for the EGWP plan. | Select One | |
| 1.1.11 | Offeror must provide descriptions of the other formulary options available to AlaskaCare in column D. At this time there is no need to provide the revised pricing under these alternative formulary options. | ||
| 1.1.12 | Offeror must confirm they shall allow members to obtain formulary excluded drugs with a prior authorization for medical necessity under your proposed offer without impacting the proposed rebates. | Select One | |
| 1.1.13 | Offeror must confirm they have provided information of the offeror's process to implement new non-specialty and specialty drug formulary exclusions, within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.1.14 | Offeror must confirm AlaskaCare has the right to opt in or opt out of any additional non-specialty/specialty formulary drug exclusions during the term of the contract without penalty or an impact to the contractual pricing. | Select One | |
| 1.1.15 | a.) Offeror must confirm they agree to notify AlaskaCare and its designee 90 days in advance of when a drug is targeted to be excluded from coverage or moved to/from the non-specialty and specialty preferred drug list. Exclusions that shall impact members negatively shall only be implemented annually. | Select One | |
| b.) Offeror must confirm they shall provide a detailed disruption and financial impact analysis at the same time. | Select One | ||
| c.) Offeror must confirm they agree no greater than 2% of members shall be disrupted by any non-specialty and specialty formulary deletions or all deletions in total on an annual basis. | Select One | ||
| 1.1.16 | Offeror must confirm they agree to notify members 60 days in advance of when a member's utilized drug is targeted to be removed from the non-specialty and specialty preferred drug list and thus become excluded from coverage. The offeror must provide at least two notifications to the members with the formulary alternative. The offeror must use a 180-day lookback period to determine potential utilizers. | Select One | |
| 1.1.17 | Offeror must confirm they agree to notify physicians of affected members 60 days in advance of when a member's utilized drug is targeted to be removed from the non-specialty and specialty preferred drug list and thus become excluded from coverage. The offeror must agree to send at least two notices to prescribers for medications that require prior authorization. | Select One | |
| 1.1.18 | Offeror must confirm they agree to notify AlaskaCare or its designee 90 days in advance of when a drug is targeted to change tiers or be moved to or from a preferred or non-preferred non-specialty/ specialty formulary tier. The offeror must provide a detailed disruption and financial impact analysis at the same time within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.1.19 | Offeror must confirm they agree to notify members 60 days in advance of when a member's utilized drug is targeted to be moved to a higher cost tier. The offeror must provide at least two notifications to the members with the formulary alternative. The offeror must use a 180-day lookback period to determine potential utilizers. | Select One | |
| 1.1.20 | Offeror must confirm they agree to notify physicians of affected members 60 days in advance of when a member's utilized drug is targeted to be moved to a higher cost tier. | Select One | |
| 1.1.21 | a.) Offeror must confirm they have provided a description of their process on how impacted members shall be communicated to regarding formulary drug exclusions or shifts from a Preferred to a Non-Preferred Tier within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| b.) For item a.) above, offeror must confirm they have explained how a member would be able to know how to fill an excluded drug through a Prior Authorization for medical exception within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| 1.1.22 | Offeror must confirm they shall be able to provide a list of the non-preferred brand drugs that are covered by AlaskaCare upon request at any time during the term of the commercial and EGWP contracts. | Select One | |
| 1.1.23 | Offeror must confirm they agree to grandfather AlaskaCare's current formulary for up to 90 days following the contract effective date with no impact on rebate guarantees if AlaskaCare requests it. | Select One | |
| 1.1.24 | Offeror must confirm no new drug therapies shall be covered for the first six months a drug is available in the market. | Select One |
| 1.2. Clinical Programs (RFP Sec. 3.05) | Confirmation | Answer | |
| 1.2.1 | In tab five, titled Clinical Programs Employee, the offeror must provide a complete list of their clinical programs with pricing and projected savings associated with each program and highlight those programs recommended for the plan. Describe the type of impact members will face for each of these programs. | Select One | |
| 1.2.2 | In tab 10, titled Clinical Programs NonEGWP, offeror must provide a complete list of their clinical programs with pricing and projected savings associated with each program and highlight those programs recommended for the plan. Describe the type of impact members will face for each of these programs. | Select One | |
| 1.2.3 | In tab 14, titled Clinical Programs EGWP, offeror must provide a complete list of their clinical programs with pricing and projected savings associated with each program and highlight those programs recommended for the EGWP plan. Describe the type of impact members will face for each of these programs. | Select One | |
| 1.2.4 | Offeror must confirm all pricing submitted is NOT contingent on participation in any proposed clinical management programs, group medical or behavioral health programs proposed by the offeror or any subcontractor other than those programs that are requested by AlaskaCare. | Select One | |
| 1.2.5 | a.) Offeror must confirm they have provided descriptions of their process to introduce new clinical programs to AlaskaCare that would take into consideration what is currently in place, what is needed and what is no longer needed within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| b.) Offer must confirm they have described how they shall provide adequate time to inform AlaskaCare about the program, provide AlaskaCare with member and financial specific information and allow AlaskaCare sufficient time to come up with a decision on the program within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| 1.2.6 | Offeror must confirm they have provided descriptions of their Prior Authorization, Drug Quantity Management, Step Therapy capabilities for non-specialty and specialty drugs within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.2.7 | a.) Offeror must confirm they offer an optional Comprehensive Utilization Management program that includes all their Prior Authorization, Drug Quantity Management and Step Therapy edits for all non-specialty and specialty drugs. | Select One | |
| b.) Offeror must confirm that AlaskaCare is able to enroll in the Comprehensive Utilization Management program or is able to elect not to enroll in this program without affecting the proposed financial guarantees. | Select One | ||
| c.) Offeror must provide the name of the program and the applicable fees whether the fees are on a Per Member Per Month basis or on a per occurrence basis in column D. | |||
| 1.2.8 | Offeror must confirm they shall provide information, including potential financial impact to the pricing guarantees, regarding a potential utilization management program to target a specific drug or drug classes within 30 calendar days of AlaskaCare's request. | Select One | |
| 1.2.9 | Offeror must confirm they shall keep accurate and detailed records regarding every prior authorization that is approved and that these records shall be available for AlaskaCare's review or its auditor's review upon request. | Select One | |
| 1.2.10 | a.) Offeror must confirm they have concisely described their capabilities surrounding e-Prescribing within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| b.) Offeror must indicate if the member's physician will be able to see the formulary status of a drug and enter the prior authorization criteria into the e-Prescribing tool in column D. | Select One | ||
| 1.2.11 | Offeror must confirm they shall only charge a Prior Authorization fee once for the review of a member's single prescription and shall not charge a fee multiple times if the member/provider does not respond in a timely manner to requests for additional information or if the member/provider makes the request to review the drug again. | Select One | |
| 1.2.12 | Offeror must confirm they shall guarantee the total Prior Authorization fee charges shall not be greater than AlaskaCare's Net Cost (before rebates) for the claim that is ultimately filled. | Select One | |
| 1.2.13 | a.) Offeror must indicate if they are able to exclude bulk chemical compound medications in column D. | Select One | |
| b.) If so, offeror must confirm they have provided details on what AlaskaCare will need to do in order to ensure the PBM excludes bulk chemical compound medications from their coverage within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| 1.2.14 | Offeror must confirm they have provided descriptions of their capabilities regarding compounds and their ability to only administer them when it is clinically appropriate within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.2.15 | Offeror must confirm they have provided the discounts, dispensing fees and logic associated with the compounds they administer when it is clinically appropriate within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.2.16 | Offeror must confirm they have described their home infusion capabilities. Provide the contractual discounts, dispensing fees, administrative fees and rebates they are proposing to AlaskaCare for home infusion claims within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.2.17 | Offeror must confirm they have provided descriptions of their capabilities to use medical claims data and prescription claims data to identify safety and health risks within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.2.18 | Offeror must confirm they have provided descriptions of their online and mobile app capabilities to allow plan sponsors to view actionable items and enhance the care for patients with chronic and complex conditions within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.2.19 | Offeror must confirm they have provided descriptions of their programs to better manage high-cost non-specialty generics and brands, including Hepatitis C, Diabetes and Oncology products in their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.2.20 | Offeror must confirm they have provided descriptions of the PBM's process to better manage drug inflation and hyperinflation drugs within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.2.21 | a.) Offeror must confirm they shall provide AlaskaCare with a utilization management program for every non-specialty drug with an ingredient cost of over $1,000 per 30 days' supply. | Select One | |
| 1.2.22 | Offeror must confirm they have provided a description of how the PBM shall manage Non-FDA approved drugs based on AlaskaCare's benefits coverage within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.2.23 | Offeror must confirm they have provided a description of how on they shall manage DESI drugs based on AlaskaCare's benefits coverage within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.2.24 | Offeror must confirm they have provided a description of how they shall manage 510k products based on AlaskaCare's benefits coverage that excludes 510k products from coverage within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.2.25 | Offeror must confirm non-essential drugs such as high-cost, low value kits, etc., can be automatically excluded from coverage. | Select One | |
| 1.2.26 | Offeror must confirm they have provided examples of success with managing specialty costs for other clients within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.2.27 | a.) Offeror must indicate if they have edits or programs in place designed to detect, address potential drug fraud and/or abuse and notify AlaskaCare in column D. | Select One | |
| b.) If yes, offeror must confirm they have explained and included a listing of the specific drugs targeted by this program within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| c.) If yes, offeror must confirm they have described the enrollee outreach after fraud or abuse is identified within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| d.) If yes, offeror must confirm they have detailed the controls put into place after fraud or abuse is identified within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| 1.2.28 | a.) Offeror must indicate if they require two generic products in order for a brand drug with a DAW 1 or 2 code to get the DAW penaltyin column D. | Select One | |
| b.) Offeror must indicate if their DAW penalty process applies to just DAW 1 and DAW 2 or all DAW codes in column D. | Select One | ||
| c.) Offeror must confirm they have described any additional details on how your organization's DAW penalty process works within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| d.) Offeror must indicated if their process allows for an appeals process that allows a member's doctor to provide information showing that the brand name drug is medically necessary in column D. | Select One | ||
| e.) If so, Offeror must confirm they have shown how this process works and provided if the regular brand discount, fee, rebate, and member copay apply to that drug within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| 1.2.29 | Offeror must confirm they shall provide medication therapy management services consistent with CMS requirements and provide AlaskaCare with quarterly reporting on all MTM activities. | Select One |
| 1.3. Retail Network Management (RFP Sec. 3.05) | Confirmation | Answer | |
| 1.3.1 | Offeror must confirm their pricing guaranteed proposed for the Commercial Plan reflects the PBM's broad Retail 30 national network similar to what is currently in place. Indicate the name of the proposed Retail 30 network. | Select One | |
| 1.3.2 | Offeror must confirm the pricing guaranteed proposed for the Commercial Plan reflects a broad Retail 90 network similar to what is currently in place. Indicate the name of the proposed Retail 90 network and the participating retail pharmacies. | Select One | |
| 1.3.3 | a.) Offeror must confirm their pricing guaranteed proposed for the Commercial Plan reflects a Retail 90 network that includes multiple retail chains at the mail order copay and mail order pricing to AlaskaCare similar to what is currently in place. | Select One | |
| b.) Offeror must confirm they have provided the names of the retail chain(s) that are part of their proposed Retail 90 network that allows members to pay the mail order copay and AlaskaCare obtain the mail order pricing within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| 1.3.4 | a.) The Commercial Plan's current plan design encourages members to fill maintenance medications at mail/Retail 90 but does not apply a penalty if the member continues to fill a 30-day supply. Offeror must indicate if they are able to administer this plan design in column D. | Select One | |
| b.) If so, offeror must confirm they have shown how they determine which drugs are “maintenance” drugs, and what is the process for the offeror to update that list, within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| 1.3.5 | Offeror must confirm the pricing guaranteed for the EGWP plan reflects their broad Retail 30 national network and indicate the name of the proposed Retail 30 network. | Select One | |
| 1.3.6 | Offeror must confirm the pricing guaranteed for the EGWP plan RFP reflects a broad Retail 90 network. Indicate the name of the proposed Retail 90 network and the participating retail pharmacies. | Select One | |
| 1.3.7 | a.) Offer must confirm the pricing guaranteed for the EGWP plan reflects a Retail 90 network that includes multiple retail chains at the mail order copay and mail order pricing to AlaskaCare similar to what is currently in place. | Select One | |
| b.) Offeror must confirm they have provided the names of the retail chain(s) that are part of their proposed Retail 90 network that allows members to pay the mail order copay and AlaskaCare obtain the mail order pricing within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| 1.3.8 | Offeror must confirm they have provided descriptions of the other retail network options that are not part of this proposal, but are available to AlaskaCare, within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). At this time there is no need to provide the revised pricing under these alternative retail network options. | Select One | |
| 1.3.9 | Offeror must confirm they shall provide service statistics and service performance guarantees, such as waiting times, related to medications dispensed via these proposed retail 90 pharmacies. | Select One | |
| 1.3.10 | Offeror must confirm they shall not remove any participating pharmacies that impacts greater than 2% of AlaskaCare's prescriptions without communicating to AlaskaCare at least 60 days in advance of the scheduled change. If the change is not agreeable to AlaskaCare, AlaskaCare will have the right to terminate the contract without penalty with 30 days' notice. | Select One | |
| 1.3.11 | Offeror must confirm they agree to offer improved pricing terms to AlaskaCare if greater than 2% of utilizing members are impacted by proposed changes to the participating pharmacy network. | Select One | |
| 1.3.12 | Offeror must confirm that they offer a performance guarantee that at least 95% of members will have access to a network pharmacy within a five-mile radius of their residence. | Select One | |
| 1.3.13 | a) Offeror must confirm whether mail order pharmacies such as Pillpak, Amazon, Hims & Hers Health, Get Roman, Cuban etc. that do not have traditional “brick and mortar” locations shall be allowed in AlaskaCare's retail network. | Select One | |
| b) Offeror must confirm whether AlaskaCare will have the option to exclude these pharmacies from the retail network. | Select One | ||
| 1.3.14 | Offeror must confirm AlaskaCare reserves the right to remove any retail pharmacy from its retail pharmacy network. | Select One | |
| 1.3.15 | a.) Offeror must confirm they shall not withhold any financial recoveries from audits performed on the contracted pharmacy network including retail, mail order and specialty pharmacies. | Select One | |
| b.) Offeror must confirm any recoveries shall be disclosed and credited to AlaskaCare. | Select One | ||
| c.) Offeror must confirm they shall provide, on a quarterly basis, a summary of AlaskaCare's retail network audits and recovery payments provided to AlaskaCare. | Select One | ||
| 1.3.16 | Offeror must confirm shall not charge AlaskaCare or offset any costs from a pharmacy audit recovery even if they must pursue additional collection action to recover pharmacy audit discrepancies. | Select One | |
| 1.3.17 | Offeror must confirm they shall maintain the retail pharmacy audit recovery fee paid to offeror at 0% of the collections throughout the life of the contract. | Select One | |
| 1.3.18 | Offeror must confirm they shall recover all outstanding payments from retail pharmacies as a result of incorrect charges and pay all the amounts owed from these audits to the client regardless of whether the offeror is able to recover all these amounts from the delinquent retail pharmacies. | Select One | |
| 1.3.19 | Offeror must confirm they have provided a description of the escalation process for urgent drug claim issues in which a claim is rejecting at the pharmacy and members need immediate assistance and resolution within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One |
| 1.4. Copay Assistance Program (RFP Sec. 3.05) | Confirmation | Answer | |
| 1.4.1 | a.) Offerors must confirm they agree to have programs in place to counter the use of manufacturer's coupons/copay assistance cards for non-specialty drugs and specialty drugs that promote the dispensing of higher cost brand name drugs when a lower cost generic or alternative is available. | Select One | |
| b.) Offeror must confirm they have described their strategy to combat the use of manufacturer's coupons/copay assistance cards within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| c.) Offeror must confirm there is no cost to AlaskaCare for any programs in place to counter the use of manufacturer's coupons/ copay assistance cards for non-specialty drugs and specialty drugs that promote the dispensing of higher cost brand name drugs when a lower cost generic or alternative is available. | Select One | ||
| 1.4.2 | a.) Offeror must confirm they can administer a specialty drug, including specialty generic products and biosimilars, variable copay plan design/ copay assistance program to leverage available specialty drug and biosimilar manufacturer patient assistance programs at both Retail and Specialty Pharmacies. | Select One | |
| b.) Offeror must indicate if the proposed copay assistance program is managed by the PBM or a subcontractor. | Select One | ||
| c.) Offeror must Indicate the name of the subcontractor, if applicable. | Select One | ||
| 1.4.3 | In tab six, titled Copay Assistance Employee, offeror must provide a list of drugs, and the respective monthly/annual copay limit, included in your variable copay plan design for the Commercial Plan. | Select One | |
| 1.4.4 | Estimated Member Savings | ||
| a.) Based on the claims data issued with the RFP and the offeror’s projection of costs and utilization January 1, 2026 - December 31, 2026, offeror must confirm they have provided their estimated member cost impact as a result of this variable copay program for non-specialty drugs and specialty drugs within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| b.) Based on the claims data issued with the RFP and the offeror’s projection of costs and utilization January 1, 2027 - December 31, 2027, offeror must confirm they have provided their estimated plan paid impact as a result of this variable copay program for non-specialty drugs and specialty drugs within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| 1.4.5 | Plan Savings | ||
| a.) Offeror must confirm they have provided their estimated savings as a result of this variable copay program for non-specialty drugs and specialty drugs for the period January 1, 2026 - December 31, 2026 within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| b.) Offeror must confirm they have provided their guaranteed savings as a result of this variable copay program for non-specialty drugs and specialty drugs for the period January 1, 2026 - December 31, 2026 within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| 1.4.6 | a.) Offeror must confirm their proposed copay assistance program/ variable copay plan design program shall not seek assistance from charitable foundations and shall not require members to provide personal income and financial information to the copay assistance program. | Select One | |
| b.) Offeror must confirm assistance from charitable foundations shall not be mandatory and shall only be optional at the member's request. | Select One | ||
| 1.4.7 | Offeror must confirm they can administer a non-specialty drug variable copay plan design to leverage available non-specialty drug manufacturer patient assistance programs at Retail. | Select One | |
| 1.4.8 | Offeror must indicate if they have a variable copay program for non-specialty drugs at retail. If not available, offeror must confirm they have provided their plans to develop one within the next 12 months within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form) in column D. | Select One | |
| 1.4.9 | For the variable copay plan design currently administered, offeror must confirm they shall be able to exclude the portion of cost funded by the manufacturer from a member's accumulators (i.e., out-of-pocket maximum). | Select One | |
| 1.4.10 | a.) Offeror must confirm they have described their member enrollment process in the patient assistance program under the variable copay plan, including the role of the member, PBM, and pharmacy within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| b.) Offeror must confirm they have described the claims adjudication process under the variable copay plan, including the role of the member, PBM, and pharmacy within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| 1.4.11 | Offeror must indicate whether they currently have (or shall have) work with outside vendors that specialize in procuring alternative funding for specialty drugs who have been selected by AlaskaCare and not the outside vendor selected by the offeror in column D. | Select One | |
| 1.4.12 | Offeror must confirm they have described how they expect to maximize the available copay assistance programs for certain non-specialty products that are also dispensed via the Specialty Pharmacy such as HIV and Transplant products within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One |
| 1.5. Audit Rights (Applies to both the Commercial and EGWP with enhanced plan design contracts) (RFP Sec. 3.05) | Confirmation | Answer | |
| 1.5.1 | Offeror must confirm the State’s Right to Audit: The offeror agrees to extend annual audit rights to AlaskaCare and to cooperate with any outside audit firm AlaskaCare selects to perform a claim administration audit. This might include the provision of space and system terminals for a reasonable period of time to accomplish the audit objectives. Audits may include claims, services, and pricing and/or rebates, including the manufacturer rebate contracts held by the PBM, to verify compliance with all program requirements and contractual guarantees with no additional charge from the PBM. | Select One | |
| 1.5.2 | Offeror must confirm that AlaskaCare's auditor does not need to be mutually agreed upon by the PBM and shall be selected at the sole discretion of the State. The auditor shall be required to sign a confidentiality agreement. | Select One | |
| 1.5.3 | Offeror must confirm that AlaskaCare will have the right to use an auditor of its choice for rebate audits, and the auditor of manufacturer agreements may be an auditing consulting company and is not restricted to a mutually agreed upon CPA accounting firm whose audit department is a separate stand-alone division of the business, which carries insurance for professional malpractice. | Select One | |
| 1.5.4 | a.) Offeror must confirm that AlaskaCare or its designee will have the right to audit up to the last three complete contractual years (36 months) of claims at no additional charge from the offeror. | Select One | |
| b.) Offeror must confirm that all audits shall not be limited to information relating to the calendar year (or plan year) in which the audit is conducted or the immediately preceding calendar year (or plan year). | Select One | ||
| 1.5.5 | Offeror must confirm that AlaskaCare or its designee will have the right to conduct an audit at any time during the year, at any point during the contract term, and the selected offeror shall provide all documentation necessary to perform the audit. | Select One | |
| 1.5.6 | Offeror must confirm that AlaskaCare will not be held responsible for time or miscellaneous costs incurred by the offeror in association with any audit process including, all costs associated with provision of data, audit finding response reports, or systems access, provided to AlaskaCare or its designee by the offeror during the life of the contract. Note: This includes any data required to transfer the business to another vendor and money collected from lawsuits and internal audits. | Select One | |
| 1.5.7 | Offeror must confirm that they shall provide complete claim files and documentation (i.e., full claim files, financial reconciliation reports, inclusion files, and plan documentation) to the auditor within 15 calendar days of receipt of the audit data request as long as a non-disclosure agreement is in place between the auditor and the offeror. | Select One | |
| 1.5.8 | Offeror must confirm that they shall not set a maximum of claim samples per audit. AlaskaCare or the auditor, on behalf of AlaskaCare, will be able to audit 100% of all pharmacy claims. | Select One | |
| 1.5.9 | Offeror must confirm that they agree to a 30-calendar day turnaround time to provide the full responses to all of the sample claims, suspected errors and claims audit findings regardless of the number of claim samples sent to the offeror or the number of years that encompass the scope of the audit. | Select One | |
| 1.5.10 | a.) Offeror must confirm that AlaskaCare or its designee will have the right to audit the greater of 12 pharmaceutical manufacturer contracts or the pharmaceutical manufacturer rebate contracts that account for 70% of the total rebate payments during the selected audit period during an on-site rebate audit. | Select One | |
| b.) Offeror must confirm these are actual pharmaceutical manufacturer contracts and not contracts with a rebate aggregator. | Select One | ||
| 1.5.11 | The offeror shall correct any errors that AlaskaCare, or its representative, brings up to the offeror's attention whether identified by an audit or otherwise. Offeror must confirm they have described the process that the offeror shall undergo to correct the error and make the appropriate payments to the member and/or AlaskaCare, if applicable, within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.5.12 | Offeror must confirm the audit provision shall survive the termination of the agreement between the parties for a period equivalent to the initial term of the contract. | Select One | |
| 1.5.13 | Offeror must confirm only AlaskaCare, or the auditor on behalf of AlaskaCare, is able to formally close an audit initiated by AlaskaCare or the auditor on behalf of AlaskaCare. | Select One | |
| 1.5.14 | Offeror must confirm that AlaskaCare will be able to initiate a new audit even if all parties have not agreed that the prior audit is closed. | Select One | |
| 1.5.15 | Offeror must confirm that AlaskaCare will have the ability to fully inspect the contracts between participating pharmacies and the offeror for up to 80% of retail pharmacy claims if AlaskaCare selects a fully-pass through pricing arrangement. | Select One | |
| 1.5.16 | Offeror must confirm they have provided a document outlining the Audit Rights and Procedures as an attachment to their technical proposal. Provide the name of the attachment in column D. | Select One |
| 1.6. Implementation (Applies to both the Commercial and EGWP with enhanced plan design contracts) (RFP Sec. 3.05) | Confirmation | Answer | |
| 1.6.1 | Offeror must confirm they are able and fully committed to support the State of Alaska with all aspects of the implementation process. Offeror must confirm they have provided an implementation timetable with a key task checklist withn their technical proposal including a separate implementation plan for each plan group, Active Employees, Non-EGWP Retirees and EGWP Retirees (Submittal Form G – Contractual Requirements Narrative Response Form)(RFP Sec. 3.01). | Select One | |
| 1.6.2 | Offeror must confirm they agree to load all current prior authorizations, open mail order refills, specialty transfer files, claim history files, and accumulator files that exist for current members from the State’s current PBM provider at NO charge to AlaskaCare (with no charges being deducted from the implementation allowance for file loading or IT). | Select One | |
| 1.6.3 | a.) Offeror must confirm they have described how prior authorizations and step therapies shall work for those members that have already gone through the process prior to the implementation date using the claims history file, open mail refill file and a prior authorization file for only the past 12 months within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| b.) Offeror must confirm they have described how these members will be impacted at a retail pharmacy, assuming the member is paying the higher copay for maintenance drug refills at retail, and via mail order within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| 1.6.4 | Offeror must confirm they agree to send at least 12 months of claims history data, all current prior authorizations, open mail order refills, specialty transfer files, and accumulator files that exist for AlaskaCare members to the next/successor PBM at NO charge if AlaskaCare terminates the contract with or without cause. | Select One | |
| 1.6.5 | Offeror must confirm they agree to waive any charges to AlaskaCare or AlaskaCare's medical plan claims administrators such as a set-up fee, a programming fee, or a monthly fee, for establishing a connection with a Third Party Administrator/Claims processor for real-time, bi-directional data integration, including non-standard data integration formats. | Select One | |
| 1.6.6 | Offeror must confirm they agree to work with AlaskaCare's auditor during a pre/post implementation audit to run test claims in a test environment utilizing AlaskaCare's actual plan parameters. | Select One | |
| 1.6.7 | Offeror must confirm they shall provide draft Summary Plan Description (SPD) language for any clinical programs that are to be implemented. | Select One | |
| 1.6.8 | Offeror must confirm they shall have a member-friendly website as well as AlaskaCare's specific toll-free telephone number available to all plan members prior to the go-live date. | Select One |
| 1.7. Member Services and Account Management (RFP Sec. 3.05) | Confirmation | Answer | |
| 1.7.1 | Offeror must confirm they agree to provide appropriately trained designated Account Manager, Implementation Manager, Clinical Pharmacist, Member Services Manager and Medicare Part D/EGWP Expert that are familiar with AlaskaCare’s industry. | Select One | |
| 1.7.2 | Offeror must confirm they shall employ sufficient and appropriately trained designated staff, familiar with administering the offeror’s proposed plan of benefits, to meet the service specifications outlined herein and subsequently detailed in a Performance Standards agreement that will be executed between AlaskaCare and your company. | Select One | |
| 1.7.3 | a.) Offeror must confirm their Account Team shall be available to meet with AlaskaCare and update an action log on a weekly basis. | Select One | |
| b.) Offeror must confirm their Account Team shall be available to meet with AlaskaCare quarterly, in person at the State's office in Juneau, Alaska, to review utilization reports and service performance metrics. | Select One | ||
| c.) Offeror must confirm their Account Manager shall be responsible for overseeing the task log and ensuring each identified issue is addressed until resolution is achieved. | Select One | ||
| d.) Offeror must confirm they shall include a Performance Guarantee on the Account Team's responsiveness. | Select One | ||
| 1.7.4 | Offeror must confirm they agree to obtain AlaskaCare's approval for all member communication materials before distribution to members. The offeror shall not automatically enroll AlaskaCare in any programs that involve any type of communications with members or alterations of members' medications, without express written consent from AlaskaCare. | Select One | |
| 1.7.5 | Offeror must confirm that AlaskaCare reserves the right to review, edit, or customize any communication from the offeror to the plan members. | Select One | |
| 1.7.6 | Offeror must confirm they have described how they shall personalize member communications based on AlaskaCare's various demographics (e.g., age, new hires) and type of enrolled plan (e.g., Active Employees, Non-EGWP Retirees and EGWP Retirees) within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.7.7 | Offeror must confirm that postage is included when mailing new ID cards and replacement cards. | Select One | |
| 1.7.8 | Offeror must confirm they shall be able to print out the full name of the primary member and dependents on the ID Card. | Select One | |
| 1.7.9 | Offeror must confirm they have described how they shall ensure they do not create unnecessary duplicate ID cards that could be incorrectly charged to AlaskaCare when receiving and loading eligibility files within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.7.10 | Offeror must confirm members will be able to print out ID Cards from the offeror’s website and members will be able to see their ID Cards from the offeror’s mobile App. | Select One | |
| 1.7.11 | Offeror must confirm they have described the process on how the member will be able to access the ID card if the member has not received the initial member ID card package by the effective date, within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.7.12 | a.) Offeror must confirm that all member service call recordings and notes between AlaskaCare's members and the offeror, the offeror’s-owned pharmacies, and the offeror's subcontractors will be AlaskaCare's property. | Select One | |
| b.) Offeror must confirm that all recordings and notes shall be stored by the offeror, the offeror-owned pharmacies and/or the offeror's subcontractors for a minimum of 36 months after contract termination at no additional cost to AlaskaCare. | Select One | ||
| 1.7.13 | a.) Offeror must confirm they agree to document 100% of AlaskaCare's member service calls through call recordings and call notes. | Select One | |
| b.) Offeror must confirm they will forward written transcripts of calls at AlaskaCare's request within two business days of the request being made. | Select One | ||
| 1.7.14 | a.) Offeror must confirm they agree that AlaskaCare reserves the right to access all call recordings or call notes from member service calls with its members. | Select One | |
| b.) Offeror must confirm they agree to allow AlaskaCare the right to request call recordings and/or notes at any time. | Select One | ||
| c.) Offeror must confirm they agree to allow AlaskaCare to listen to any recorded calls within 24 hours of AlaskaCare's request. | Select One | ||
| 1.7.15 | Offeror must confirm that all customer service operations requiring verbal communication with AlaskaCare and AlaskaCare's members will be performed in the United States (i.e., will not be provided offshore). This requirement includes work performed by the offeror and approved subcontractors. | Select One | |
| 1.7.16 | Offeror must confirm, if awarded this contract, the offeror shall provide AlaskaCare with a virtual tour of the offeror’s customer service representative (CSR) system and any custom messaging system. Details and scheduling of the demonstration will be coordinated between the Project Manager and the awarded Offeror. | Select One | |
| 1.7.17 | Offeror must confirm they have described their process for providing training to member service representatives to serve a senior membership (EGWP), within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.7.18 | Offeror must confirm they have provided information on programs the offeror’s organization offers that would allow members to contact the same Care Representative, within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.7.19 | Offeror must confirm that multi-language communication phone line support is included in the base administrative fee. List the languages available to AlaskaCare members speaking to your customer service representatives. | Select One | |
| 1.7.20 | a.) Offeror must confirm they have detailed how they track member complaints within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| b.) Offeror must confirm they have listed the top five member complaints related to retail, mail order, and the specialty pharmacy program within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| c.) Offeror must confirm they have described their processes and remedies in place to resolve these complaints within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| 1.7.21 | Offeror must indicate if they maintain statistics with respect to member service telephone response time, abandonment, and inquiries made in column D. | Select One | |
| 1.7.22 | Offeror must confirm they have detailed how disabled (e.g., hearing-impaired) member calls are facilitated through their member services area within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.7.23 | Offeror must confirm they agree to, at minimum, quarterly calls to review member service issues and that they agree to allow AlaskaCare to review member service quality issues to the resolution endpoint. | Select One | |
| 1.7.24 | Offeror must confirm they have listed the functions members can perform using their member website and member mobile app within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.7.25 | Offeror must indicate if members can view real time discount price by drug and pharmacy via the offeror’s website, mobile app and call center in column D. | Select One | |
| 1.7.26 | Offeror must confirm they have provided images of their member website layout as an attachment to their technical proposal. Submitted images must remain anonymous and shall not contain any names, logos, or other identifying marks that could identify the offeror. Provide the name of the attachment in column D. | Select One | |
| 1.7.27 | Offeror must confirm they agree to provide different levels of access to each of AlaskaCare's designees to the online real time claim system so that not all AlaskaCare's designees are able to see all details related to all member claims in the system. | Select One | |
| 1.7.28 | a.) Offeror must confirm they have provided a standard reporting package sample, as an attachment to their technical proposal, and has noted the frequency which these reporting packages shall be provided to AlasakCare in column D. Provide the name of the attachment in column D. | Select One | |
| b.) Offeror must confirm the standard reporting package can be sent to AlaskaCare on a quarterly or annual basis, at AlaskaCare’s request, within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | ||
| 1.7.29 | Offeror must confirm they agree that all future edits required because of plan design changes implemented by AlaskaCare shall be completed, after testing, by the offeror within 45 days of request/advisory by AlaskaCare. | Select One | |
| 1.7.30 | a.) Offeror must confirm they shall fully disclose any and all sub-contracted work. | Select One | |
| b.) Offeror must confirm they shall not provide any AlaskaCare services offshore. | Select One | ||
| 1.7.31 | Offeror must confirm they have described what portion of AlaskaCare's business shall be serviced by a subcontractor, or through leased services/networks, within their technical proposal (Submittal Form G – Contractual Requirements Narrative Response Form). | Select One | |
| 1.7.32 | Offeror must confirm they shall provide AlaskaCare with a 90-day advance notice of any changes in suppliers or subcontractors for services such as specialty pharmacy, mail-order facility and/or other products and services. | Select One |
| 1.8. Legal Responsibilities (RFP Sec. 3.05) | Confirmation | Answer | |
| 1.8.1 | General Compliance: Offeror must confirm all services adhere to relevant federal and state laws and regulations. | Select One | |
| 1.8.2 | HIPAA Compliance: Offeror must confirm all systems and services are compliant with HIPAA EDI, Privacy, and Security regulations on the appropriate dates established by the Department of Health & Human Services. | Select One | |
| 1.8.3 | Offeror must confirm they shall indemnify, defend and hold harmless AlaskaCare, its officers, directors, employees and agents and affiliates from and against any and all claims, actions, demands, costs, and expenses, including reasonable attorney fees and disbursements, as a result of a breach by the PBM of any of its obligations under the Commercial and EGWP with enhanced plan design Agreements or arising out of the negligent act or omission or willful misconduct of the PBM or its employees or agents. | Select One | |
| 1.8.4 | Offeror must confirm the indemnification set forth above in 1.8.3 shall cover a breach of protected health information. | Select One | |
| 1.8.5 | Offeror must confirm they are compliant with the Electronic Data Interchange (EDI), Privacy and Security Rules of the Health Insurance Portability and Accountability Act (HIPAA) and shall execute the appropriate Business Associate Agreement (BAA). PBM also agrees that in the event of a privacy violation or data breach, that the PBM shall notify AlaskaCare and the impacted members to a breach and provide any required remedies. | Select One |
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