Attachment 7 CA2 - PWS Changes.pdf

Changes to Performance Work Statement (PWS)

For

Office of Workers’ Compensation Programs (OWCP) Pharmacy Benefits Management (PBM) Services

NOTE: The below provides changes to requirements as follows: 5.1.4.1 Prior Authorization Portal and

5.1.4.4 PBM Utilization Review. The requirements for 5.1.4.1 and 5.1.4.4 are presented in their entirety, including any sub-items not changed from prior communications.

5.1.4.1 Prior Authorization Portal. The contractor shall implement a user interface (UI) to transmit pharmacy authorization requests and messaging to DOL that provides case-specific coverage recommendations (e.g., recommend step therapy, recommend approval, recommend denial) on drug authorization, based on evidence-based best practice.

The contractor coverage recommendations must clearly articulate the rationale for prior approval or denial, stating the specific attributes of the case, such that DOL can incorporate it into any communication with the injured worker and prescribing physician. The contractor’s UI must be capable of generating and transmitting such case-specific coverage recommendations on all (100%) prior authorization or other hard edits that may involve a coverage decision required by OWCP staff at the start of Phase 3. Daily data files of these authorization requests and documentation of accompanying messages may be required.

5.1.4.1.1 The contractor shall coordinate with the central bill process contractor, and implement interfaces where necessary.

5.1.4.4 PBM UTILIZATION REVIEW

5.1.4.4.1 The contractor shall implement a Drug Utilization Review (DUR) Program that includes both automated tools (such as software/code edits) and clinical services, and must deliver at least the following functionality:

• Detection of fraud, waste, and abuse patterns by providers or employees

• Screening for drug/drug contraindications

• Detection of duplicate prescriptions

• Detection of therapeutic overlap

• Reporting of brand name versus generic usage by drug category

• Early refill

• Prospective, concurrent, and retrospective DUR program specific to, but not restricted to, opioids, letters of medical necessity, and excessive costs.

• Require the use of generic equivalents where they are available, upon OWCP’s request.

5.1.4.4.2 The contractor shall implement a secure interface to communicate alerts directly to OWCP with findings from the

DUR process.

5.1.4.4.3 Automated Prospective Drug Utilization Review (DUR). The contractor shall customize edits to conform to program policies, and evaluate and manage pharmacy claims using real-time, point-of-sale edits consistent with program-specific formularies and policies, and industry standards. Edits must include, but shall not be limited to drug-drug interactions, drug-allergy contraindications, drug-pregnancy contraindications, therapeutic duplication, refill too soon, incorrect dosage, quantity limits, morphine milligram equivalents (MME) and/or morphine equivalent dosage (MED) per day, step therapy edits, and other situations that may endanger the health and welfare of claimants. Edits must also notify the pharmacist to obtain prior authorization for non-formulary medications, compounded drugs, opioids, and brand name medications when generic equivalents are available. The system must also allow pharmacists to override certain edits at point-of-sale using appropriate DUR reason for service codes, DUR professional service codes and DUR result of service codes based on program policies and procedures.

5.1.4.4.4 Automated Retrospective Drug Utilization Review (DUR). The contractor shall employ retrospective DUR tools, which identify and provide data on prescribers and pharmacies that prescribe or dispense in a manner outside the norm, present safety concerns, or might be engaged in potential waste, fraud, or abuse. Examples include, but are

Changes to Performance Work Statement (PWS)

For

Office of Workers’ Compensation Programs (OWCP) Pharmacy Benefits Management (PBM) Services not limited to the prescribing and dispensing excessive quantities of controlled substances, and unusually high rates of compounded or brand name drug prescriptions with instructions to dispense as written. The tools employed shall provide full visibility of each claimant’s OWCP workers compensation medication history, including medications obtained from retail, mail order, compounding, and out-of-network pharmacies; through third-party billers; and dispensed by physicians.

5.1.4.4.5 Clinical Drug Utilization Review (DUR). The contractor shall provide clinical DUR services, to include at minimum clinical personnel (Pharmacists, Nurses, Nurse Practitioners, Physicians or a combination thereof) that will contact and engage prescribers and recommend interventions in up to 4,000 cases per year and provide in such cases advice regarding particular transactions and/or medication regimens. Targeted populations for these 4,000 cases may include, but would not be limited to, those instances when potential claimant safety concerns with prescribed drugs are noted in order to encourage safe prescribing practices or when alternative options are available that may provide equally or more favorable clinical outcomes.

During performance of the contract, DOL will consult with the contractor to identify the type of cases and target populations for which clinical DUR services will be required, the proposed interventions, the expected outcome of such interventions, and an approach for ongoing support to achieve expected outcomes. DOL will direct the contractor to provide those clinical DUR services in up to 4,000 cases per year. The contractor shall conduct interventions and ongoing support by either, or a combination of, a Pharmacist, Nurse, Nurse Practitioner or

Physician. DOL will decide the combination on a case-by-case basis in response to the contractor’s clinical DUR recommendation.

Upon DOL direction, the Contractor shall proceed with the approved intervention and monitor progress at least monthly for 6 months or until achieving the expected outcome, whichever is sooner. The Contractor shall provide a written report of interventions, in electronic format, for inclusion in the claimant’s case file and for distribution to the claimant and prescribing physician, within 2 weeks of completion of the service. The written report shall be complete with references to guidelines, the medical literature, and FDA information to support the interventions.

The Contractor shall track usage of each clinical DUR intervention, by type, and the outcome of the interventions for monthly reporting to DOL.