Att 5 - Submittal Form G (Part 2 of 2) - Contractual Reqs Narrative Response Form.docx

SUBMITTAL FORM G (Part 2 of 2) Contractual Requirements Narrative Response Form

SPECIAL NOTE: The offeror shall not disclose their costs in this Submittal Form. This form shall be kept anonymous and must not contain any names that can be used to identify who the offeror is.

Offeror must keep their response concise yet comprehensive. Offeror must provide their response directly under each requirement and may expand response area as needed.

1.1. Formulary Management

1.1.13 Offeror must provide information on their process to implement new non-specialty and specialty drug formulary exclusions.

1.1.18 Offeror must 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. Offeror must provide a detailed disruption and financial impact analysis.

1.1.21 a.) Offeror must provide a description of their process on how impacted members shall be communicated regarding formulary drug exclusions or shifts from a Preferred to a Non-Preferred Tier.

b.) For item a.) above, offeror must explain how a member would be able to know how to fill an excluded drug through a Prior Authorization for medical exception.

1.2. Clinical Programs

1.2.5 a.) Offeror provide 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.

b.) Offer must describe 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.

1.2.6 Offeror must provide descriptions of their Prior Authorization, Drug Quantity Management, Step Therapy capabilities for non-specialty and specialty drugs.

1.2.10 a.) Offeror must concisely describe their capabilities surrounding e-Prescribing.

1.2.13 b.) If offeror is able to exclude bulk chemical compound medications, offeror must provide details on what AlaskaCare will need to do in order to ensure the PBM excludes bulk chemical compound medications from their coverage.

1.2.14 Offeror provide descriptions of their capabilities regarding compounds and their ability to only administer them when it is clinically appropriate.

1.2.15 Offeror provide the discounts, dispensing fees and logic associated with the compounds they administer when it is clinically appropriate.

1.2.16 Offeror describe their home infusion capabilities. Provide the contractual discounts, dispensing fees, administrative fees and rebates they are proposing to AlaskaCare for home infusion claims.

1.2.17 Offeror provide descriptions of their capabilities to use medical claims data and prescription claims data to identify safety and health risks.

1.2.18 Offeror provide 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.

1.2.19 Offeror provide descriptions of their programs to better manage high-cost non-specialty generics and brands, including Hepatitis C, Diabetes and Oncology products.

1.2.20 Offeror provide descriptions of the PBM's process to better manage drug inflation and hyperinflation drugs.

1.2.22 Offeror must provide a description of how on the PBM shall manage Non-FDA approved drugs based on AlaskaCare's benefits coverage within.

1.2.23 Offeror must provide a description of how on they shall manage DESI drugs based on AlaskaCare's benefits coverage.

1.2.24 Offeror must provide a description of how they shall manage 510k products based on AlaskaCare's benefits coverage that excludes 510k products from coverage.

1.2.26 Offeror must provide examples of success with managing specialty costs for other clients.

1.2.27 b.) If the offeror has edits or programs in place designed to detect, address potential drug fraud and/or abuse and notify AlaskaCare, offeror must explain and include a listing of the specific drugs targeted by this program.

c.) If the offeror has edits or programs in place designed to detect, address potential drug fraud and/or abuse and notify AlaskaCare, offeror must describe the enrollee outreach after fraud or abuse is identified.

d.) If the offeror has edits or programs in place designed to detect, address potential drug fraud and/or abuse and notify AlaskaCare, offeror must detail the controls put into place after fraud or abuse is identified.

1.2.28 c.) Offeror must describe any additional details on how the offeror’s DAW penalty process works.

d.) Offeror must indicate 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.

e.) If the offeror’s process allows for an appeals process that allows a member’s doctor to provide information showing that the brand name drug is medically necessary, offeror must detail how this process works and provide if the regular brand discount, fee, rebate, and member copay apply to that drug.

1.3. Retail Network Management

1.3.1 b.) Offeror must provide 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.

1.3.4 b.) If the offeror’s 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 detail how they determine which drugs are “maintenance” drugs, and what is the process for the offeror to update that list.

b.) Offeror must provide 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.

1.3.8 Offeror must provide descriptions of the other retail network options that are not part of this proposal but are available to AlaskaCare. At this time there is no need to provide the revised pricing under these alternative retail network options.

1.3.19 Offeror must provide 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.

1.4. Copay Assistance Program

1.4.1 b.) Offeror must describe their strategy to combat the use of manufacturer's coupons/copay assistance cards.

b.) Based on the claims data and the offeror’s projection of costs and utilization January 1, 2027 - December 31, 2027, offeror must provide their estimated plan paid impact as a result of this variable copay program for non-specialty drugs and specialty drugs.

b.) Offeror must provide 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.

1.4.8 If the offeror does not have a variable copay program for non-specialty drugs at retail, offeror must provide their plans to develop one within the next 12 months.

1.4.12 Offeror must describe 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.

1.5. Audit Rights (Applies to both the Commercial and EGWP with enhanced plan design contracts)

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 describe the process that the offeror shall undergo to correct the error and make the appropriate payments to the member and/or AlaskaCare.

1.6. Implementation (Applies to both the Commercial and EGWP with enhanced plan design contracts)

1.6.1 Offeror must provide an implementation timetable with a key task checklist including a separate implementation plan for each plan group, Active Employees, Non-EGWP Retirees and EGWP Retirees.

1.6.3 a.) Offeror must describe 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 the past 12 months.

b.) Offeror must describe 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.

1.7. Member Services and Account Management

1.7.18 Offeror must provide information on programs the offeror’s organization offers that would allow members to contact the same Care Representative.

1.7.20 a.) Offeror must detail how they track member complaints.

b.) Offeror must list the top five member complaints related to retail, mail order, and the specialty pharmacy program.

c.) Offeror must describe their processes and remedies in place to resolve these complaints.

1.7.22 Offeror must detail how hearing-impaired member calls are facilitated through their member services area.

1.7.24 Offeror must list the functions members can perform using their member website and member mobile app.

1.7.28 b.) Offeror must confirm the standard reporting package can be sent to AlaskaCare on a quarterly or annual basis, at AlaskaCare’s request.

1.7.31 Offeror must describe what portion of AlaskaCare's business shall be serviced by a subcontractor, or through leased services/networks.

1.9. Federal No Surprises Act, Final Transparency Rule, No Surprises Act

1.9.1 a.) Offeror must describe how they shall assure that AlaskaCare is in compliance with federal laws and regulations concerning surprise billing and transparency with respect to the services provided by the offeror.

1.9.2 Offeror must provide a list of any technical specifications that AlaskaCare will need to meet to use any solution the offeror intends to offer to comply with laws and regulations, including software, hardware, or other information technology.

1.9.3 b.) If offeror is not fully compliant with the law and regulations by the statutory and regulations due dates, offeror must provide an explanation.

1.9.4 b.) If offeror has not indicated their existing fees are inclusive of all services related to the applicable laws and regulations, offeror must provide an explanation of what additional costs AlaskaCare may incur.

c.) Offeror must describe when and how AlaskaCare would be notified of any fee modification proposals.

Transparency Rules (Not Applicable to Grandfathered Plans)

1.9.7 Offeror must describe how members access their internet-based self-service tool, through the offeror’s website, by providing information to Funds, or through another option.

1.9.12 b.) If the offeror shall provide AlaskaCare with a monthly machine-readable file, which includes prescription drug negotiated rates, offeror must describe which files shall be provided and state whether the offeror shall send information to AlaskaCare or provide another service to AlaskaCare that allows AlaskaCare to link to another website.

1.9.13 Offeror must describe the information technology requirements necessary for transmitting files and/or posting them.

No Surprises Act

1.9.17 a.) For grandfathered and non-grandfathered plans, offeror must describe how they shall support the additional External Appeals requirements for Covered Services.

1.9.18 a.) If you have a preferred provider network, offeror must describe their process for allowing continuation of care for individuals when their health care provider is terminated from the Network.

b.) Offeror must describe how patients are protected from being billed at an out-of-network rate and how the patient is provided with notice under the law.

1.9.19 d.) Offeror must describe the price comparison tool in detail and whether any subcontractors are used to produce it.

e.) Offeror must describe who shall provide the telephone tool and at what location.

j.) Offeror must describe what, if any, features are available beyond the requirements of the No Surprises Act and if AlaskaCare is able to opt out of any such features.

1.9.20 Offeror must describe their process for addressing participant or provider complaints that may be made against the plan under the Act.

1.9.21 a.) Offeror must describe how they shall assist AlaskaCare in annually reporting for prescription drug and total health claim costs and other required information to the federal government.

b.) Offeror must describe their process for reporting prescription drug and total health claim cost information to the federal government.

d.) If the offeror shall submit on an aggregated basis including AlaskaCare data, offeror must detail what information AlaskaCare will need to provide to the offeror. Offeror must describe their process for gathering any such information, including any technology specifications.

g.) Offeror must describe whether the offeror shall accept responsibility for fulfilling all cost reporting obligations and if not which ones the offeror shall not fulfill.

1.9.22 a.) The No Surprises Act requires ID cards to contain information about deductibles and out-of-pocket maximums. Offerors must describe what changes are needed to the offeror’s ID cards and how the offeror shall provide the new cards.

b.) Offeror must describe when and how new ID cards will be delivered to Plan participants.

1.9.23 Offeror must describe what benefits the offeror administers through AlaskaCare's pharmacy benefit, including specialty drugs, that are subject to the new requirement to provide plan participants with an Advanced Explanation of Benefits.

1.9.24 Offeror must detail the offeror’s process used to accept provider notification of expected charges and services.

1.9.25 Offeror must describe how the offeror shall provide the Advanced EOB to participants such as via electronic means or mail as requested by the participant.

1.9.26 Offeror must describe how the offeror shall provide reports assuring that the Advanced EOB process is performing as required by law.

1.9.27 Offeror must describe the offeror’s process for addressing participant or provider complaints that may be made against AlaskaCare under the Act.

1.9.28 Offeror must describe how the offeror shall assist AlaskaCare in reporting prescription drug costs and other information to the federal government.

1.9.29 Offeror must describe the offeror’s process for reporting prescription drug cost information to the federal government.

1.9.30 Offeror must detail which elements of the reporting requirements the offeror shall be responsible for and which requirements the offeror expects AlaskaCare to be responsible for.

1.10. Eligibility

1.10.2 Offeror must describe how the offeror defines “ID Card Reissues” and how the offeror shall determine which ID Card Reissues require a fee.

1.10.3 c.) Offeror must describe how the offeror shall determine which ID Card Reissues require a fee.

1.11. Invoicing

1.11.4 a.) Offeror must detail how the offeror shall refund AlaskaCare in instances where the offeror overcharges AlaskaCare for services that the offeror agrees have been overcharged and/or inappropriately charged.

1.12.17 Offeror must describe how the offeror shall administer the IRMAA benefit.