Attachment B - Cost Form - PBM RFP 2025.xlsx
XLSX spreadsheet 361 KB Posted
- Attached to
- Pharmacy Benefits Manager (PBM)
- Solicitation number
- RFP-758-2500000221-4
- Issued by
- Elliott County, Kentucky
About this file
This document is a Request for Proposal (RFP) for Pharmacy Benefit Management (PBM) services issued by the Kentucky Employees' Health Plan (KEHP) for the Commonwealth of Kentucky. The solicitation seeks a comprehensive PBM contract effective January 1, 2026, with a three-year base term and potential two-year extension option. The RFP requires vendors to provide a full-service PBM solution covering retail, mail order, and specialty pharmacy services, with specific requirements including NADAC (National Average Drug Acquisition Cost) reimbursement methodology, transparent pricing, and guaranteed manufacturer payment terms. The proposal must support an open specialty pharmacy network, accommodate various claim processing channels, and include detailed performance guarantees across implementation, clinical programs, customer service, and claims processing.
The financial proposal demands strict pricing transparency, with guaranteed minimum discounts, dispensing fees, and manufacturer payments across different pharmacy channels. Vendors must propose pricing on a post-AWP rollback basis, pass through 100% of manufacturer payments, and provide comprehensive reporting on rebates, claims, and clinical program outcomes. The RFP includes specific requirements around NADAC pricing for Kentucky pharmacies, with a dispensing fee of $10.64 per claim for independent pharmacies in 2026, transitioning to a fee set by the Kentucky Department of Insurance in 2027 and 2028. The proposal also requires detailed specialty drug pricing, clinical program fees, and performance guarantees, with potential financial penalties for failing to meet specified service levels and reporting requirements.
View the file
Other files
Show all 15
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Technical12.20.2024
| Request for PBM Proposal (RFP) for the Commonwealth of Kentucky (KEHP) |
| Technical |
| To Vendor: Use Column F to provide a brief explanation. However if the length of the explanation is greater than 250 characters including spaces, you must use the "Explanation" worksheet to provide your detail explanation. Please note, your explanations must be limited to 400 characters or less unless otherwise noted. | ||||
| Technical Questionnaire | Format Type | Response | Explanation | |
| Commonwealth/DEI Payment Terms | ||||
| 1. | You will not require an advance deposit, prepayment/prefunding and no imprest balance from Commonwealth/DEI. | |||
| 1: Agree, |
2: Disagree (explain): [ Text ]
2. Commonwealth/DEI will receive/pay Claim invoices on a biweekly (every two weeks) basis. Vendor must follow Commonwealth/DEI's Billing Procedure document (Attachment J), and payment for any invoice would be based on that schedule. 1: Agree, 2: Disagree (explain): [ Text ]
| 3. | You will allow Commonwealth/DEI up to thirty (30) days to pay Claim invoices. Vendor must follow Commonwealt/DEI's Billing Procedure document (Attachment J), and payment for any invoice would be based on that schedule. | 1: Agree, | ||
| 2: Disagree (explain): [ Text ] | Updated | |||
| 4. | You will allow Commonwealth/DEI to pay Administrative Fees on a monthly basis. | 1: Agree, |
2: Disagree (explain): [ Text ]
5. You will allow Commonwealth/DEI fifteen (15) business days to pay Administrative Fees. Vendor must follow Commonwealth/DEI's Billing Procedure document (Attachment J), and payment for any invoice would be based on that schedule. 1: Agree, 2: Disagree (explain): [ Text ]
6. You will be flexible in accommodating the specific banking requirements of Commonwealth/DEI. 1: Agree, 2: Disagree (explain): [ Text ]
7. You will provide detailed account structure reporting of Claims, invoiced amounts and Manufacturer Payments for accounting purposes. 1: Agree, 2: Disagree (explain): [ Text ]
8. You shall not require an advance deposit from Commonwealth/DEI prior to the effective date or at any time during the contract term. 1: Agree, 2: Disagree (explain): [ Text ]
| Rx Formulary | Format Type | Response | Response | |
| 9. | Commonwealth/DEI will have the option of utilizing your standard formulary including all FDA approved drugs or your standard formulary with its formulary exclusions. Your proposal includes Manufacturer Payment guarantees. | 1: Agree, |
2: Disagree (explain): [ Text ]
| 10. | Your proposal assumes: | ||
| a. | Commonwealth/DEI may continue Continuity of Therapy Utilization without affecting the minimum Rebate Guarantees. Manufacturer Payments with respect to Continuity of Therapy Utilization shall be (a) 100 percent pass-through; and (b) subject to the minimum Rebate Guarantees quoted on the 'Rx-Pricing, MFP' tab for up to ninety (90) days following the contract effective date. | 1: Agree, |
2: Disagree (explain): [ Text ]
b. Commonwealth/DEI continues to apply the same formulary strategy over the contract term. For instance, if Commonwealth/DEI currently utilizes a formulary that excludes certain FDA products, your proposal reflects your organization's exclusion-based formulary and associated Manufacturer Payment guarantees. 1: Agree, 2: Disagree (explain): [ Text ]
c. If you answer "Disagree" to the question above, please describe how your proposal will differ from the current formulary. 1: Agree, 2: Disagree (explain): [ Text ]
d. You agree that you will be responsible for maintaining this formulary and determining which products are preferred and non-preferred, not Commonwealth/DEI, at no additional cost to Commonwealth/DEI. 1: Agree, 2: Disagree (explain): [ Text ]
| Formulary Exclusions | Format Type | Response | Response | ||
| 11. | Should Commonwealth/DEI elect to adopt a formulary with exclusions, you agree to the following: | ||||
| a. | Provide written notice to Commonwealth/DEI at least ninety (90) calendar days in advance of any annual formulary changes, with the exception of changes due to safety and FDA-driven issues. | 1: Agree, |
2: Disagree (explain): [ Text ]
b. Provide written notice to Commonwealth/DEI at least sixty (60) calendar days in advance of any quarterly formulary changes, with the exception of changes due to safety and FDA-driven issues. 1: Agree, 2: Disagree (explain): [ Text ]
c. Provide written notice to Members sixty (60) calendar days in advance of any annual formulary changes, with the exception of changes due to safety and FDA-driven issues. 1: Agree, 2: Disagree (explain): [ Text ]
d. Provide written notice to Members thirty (30) calendar days or less where required by law in advance of any quarterly or monthly formulary changes, with the exception of changes due to safety and FDA-driven issues. [Plan is required by law to provide at least 15 days' written notice to members negatively impacted by a change, as well as to our board. See KRS 18A.2254(1)(c)]. 1: Agree, 2: Disagree (explain): [ Text ]
e. Provide written notice to Commonwealth/DEI's members within five (5) business days for any formulary changes due to safety and FDA-driven issues. 1: Agree, 2: Disagree (explain): [ Text ]
f. Provide a medical necessity exception process that will conclude within two (2) business days once information is received from the prescriber for drugs excluded from your formulary. 1: Agree, 2: Disagree (explain): [ Text ]
g. If Commonwealth/DEI does not agree to such a formulary change as described directly above, Commonwealth/DEI reserves the right to implement a custom formulary, at no additional cost, or terminate for cause, with sixty (60) calendar days written notice. 1: Agree, 2: Disagree (explain): [ Text ]
h. You will provide Commonwealth/DEI with a specific analysis identifying the financial impact (i.e. ingredient cost before and after Manufacturer Payments) and member impact of the additional exclusions on a drug-by-drug basis and in total at least ninety (90) calendar days in advance of any changes that narrow the formulary. If earned Manufacturer Payments for products remaining on the formulary increase as a result of the additional exclusions, your analysis will identify the financial impact (i.e. ingredient cost before and after Manufacturer Payments) of these improvements on a drug-by-drug basis. There will be no arbitrary or book of business adjustment applied to Commonwealth/DEI's guaranteed Manufacturer Payments. 1: Agree, 2: Disagree (explain): [ Text ]
| 12. | How many products are excluded from your proposed exclusions-based formulary? Provide a complete list of the drugs excluded from this formulary. | Number |
| 13. | Provide a list of historical exclusions as far back as 2 calendar years. | 1: Attached, |
2: Not provided
| 14. | How many of these exclusions are Traditional drugs? | Number |
| 15. | How many of these exclusions are Specialty Drugs? | Number |
| 16. | You agree that your standard formulary will include at least two drugs in every therapy class and disease state and will provide clinically appropriate access to a sufficient number of pharmaceutical products available in the marketplace. | 1: Agree, |
2: Disagree (explain): [ Text ]
17. Your agree your standard policy is to ensure that "once a generic, always a generic." In other words, Members will pay a generic copay for single-source and multi-source generics regardless of your drug-type classification policy. 1: Agree, 2: Disagree (explain): [ Text ]
| 18. | Will you allow Commonwealth/DEI and the Coalition to laser drugs from PBM standard formulary without affecting rebate guarantees? (e.g. Custom Exclusion list). | Yes/No/Explain | Added back |
| 19. | Will Commonwealth/DEI staff be able to view prior authorization case details (prior authorization criteria questions and provided responses) for all plans? | Yes/No/Explain | Added back |
| 20. | You agree to allow specific prior authorization categories to be managed by Commonwealth/DEI as opposed to the PBM. | 1: Agree, |
2: Disagree (explain): [ Text ]
21. You agree Commonwealth/DEI can self-manage coverage appeals. 1: Agree, 2: Disagree (explain): [ Text ]
22. You agree Commonwealth/DEI can self-manage Cost Exceed Maximum reviews. 1: Agree, 2: Disagree (explain): [ Text ]
23. Describe PBM offerings to support Commonwealth/DEI Disease Management programs and any Commonwealth/DEI determined copay incentives. Your response to include but not limited to: cost of such support, enrollment details, eligibility details, drug lists to support DM programs. 1: Agree, 2: Disagree (explain): [ Text ]
24. What flexibility does a plan have in terms of coverage choices of specific categories (e.g. drugs not for self-administration excluded, OTC equivalents, Etc.). 1: Agree, 2: Disagree (explain): [ Text ]
25. You agree Commonwealth/DEI can request the prior authorization department/reviewer to require clinical records/documentation to support the claims of prior medication use. 1: Agree, 2: Disagree (explain): [ Text ]
26. Please list all of your PBM's actual PA and step-therapy treatment and quantity limit programs currently available.
1: Attached, 2: Not provided
| Retail Network | Format Type | Response | Response | |
| 27. | Your bid reflects the broadest Retail network available and does not contemplate or underwrite any changes to those networks that diminishes member access. | 1: Agree, |
2: Disagree (explain): [ Text ]
28. You agree to base your bid on your broadest Retail network available that includes all major Retail chains. 1: Agree, 2: Disagree (explain): [ Text ]
29. If you propose a network change that impacts more than 5% of all pharmacies in the network (add, drop certain chains, etc.) and/or one of the top five (5) pharmacy chains by store count before the effective date and or during the contract term, you will provide a detailed analysis describing member disruption and impact to pricing with all underlying assumptions disclosed to Commonwealth/DEI at least ninety (90) calendar days prior to the effective date of the proposed network change. 1: Agree, 2: Disagree (explain): [ Text ]
30. Furthermore, should the number of Retail Pharmacies in your network be reduced by more than 3% of all pharmacies in the network (add, drop certain chains, etc.) and/or one of the top 5 pharmacy chains by store count before the effective date and or any point during the contract term, you will provide Commonwealth/DEI with an improved pricing offer for the proposed reduced Retail network at least ninety (90) calendar days prior to the effective date of such change. 1: Agree, 2: Disagree (explain): [ Text ]
31. If the revised pricing that results from a change in the pharmacy network is not acceptable to Commonwealth/DEI, they reserve the right to renegotiate pricing or terminate for cause with thirty (30) calendar days notice for the remaining term of the contract. 1: Agree, 2: Disagree (explain): [ Text ]
32. If you elect to make a change in your pharmacy network, Commonwealth/DEI's pricing cannot be negatively altered (current pricing must be honored or improved). 1: Agree, 2: Disagree (explain): [ Text ]
33. You have a network of pharmacies that will provide significantly greater discounts (i.e. similar or equal to Mail Order pricing) for Claims with an 83-90 day supply when Mail Order copays/coinsurance apply to prescriptions filled at these pharmacies. 1: Agree, 2: Disagree (explain): [ Text ]
34. We recognize that a subset of “pop up” pharmacies potentially commit fraud through the practice of opening a pharmacy for a short period of time to bill Claims, then shut down and reopen another pharmacy, repeating the process to avoid getting caught and prosecuted. What is your plan to keep such pharmacies out of Commonwealth/DEI's network? Include a detailed description of recent efforts to detect “pop up” pharmacies and specify the actions you took. 1: Agree, 2: Disagree (explain): [ Text ]
| 35. | Similarly to question 34, please describe your process for prescriber oversight – 1. Prescribing within scope of practice and 2. fraud waste and abuse oversight. | 1: Agree, | ||
| 2: Disagree (explain): [ Text ] | Updated reference #34 | |||
| 36. | Please input the number of pharmacies nationwide in your proposed Retail-90 and Mail at Retail Networks in the "RX-Pricing" Worksheets. [NOTE: Mail-order option is required for maintenance drugs. See KRS 18A.2259] | Number | ||
| 37. | You will allow Commonwealth/DEI to remove specific pharmacies from networks and Prescriber dispensing. | 1: Agree, |
2: Disagree (explain): [ Text ]
| 38. | Does your PBM apply DIR (aka Clawbacks)? | Yes/No/Explain | Updated |
| 39. | Explain your policies regarding MAC lists. Are same MAC lists applied at mail order vs. retail? Are same MAC lists applied uniformly across a Chain? What level of transparency will you provide to Commonwealth/DEI and in terms of MAC pricing? | 1: Agree, |
2: Disagree (explain): [ Text ]
40. You agree to use MAC list that will apply at PBM owned retail, mail or specialty pharmacies that include prices no higher than the ones applied to non PBM owned pharmacy claims. 1: Agree, 2: Disagree (explain): [ Text ]
41. Kentucky is an "any willing provider" state. How does this impact your network discount savings for the network offerings? 1: Agree, 2: Disagree (explain): [ Text ]
| 42. | If your PBM has a wholly owned retail pharmacy chain, how does that ownership impact discounts and fees? (Please note the requirements of KRS 304.17A-595.) | 1: Agree, | ||||
| 2: Disagree (explain): [ Text ] | Updated | |||||
| Market Check | Format Type | Response | Response | |||
| 43. | You agree to allow an annual market check to preserve competitiveness of financial terms for Commonwealth/DEI. | 1: Agree, |
2: Disagree (explain): [ Text ]
44. You agree to allow a third party vendor or consultant to perform the market checks at no additional charge to the Commonwealth/DEI. 1: Agree, 2: Disagree (explain): [ Text ]
45. You agree that no contractual term or financial component of the contract will be negatively impacted for Commonwealth/DEI as a result of the market check 1: Agree, 2: Disagree (explain): [ Text ]
46. The market check will compare the aggregate value of the discounts, dispensing fees, administration fee pricing terms of Commonwealth/DEI with the aggregate value of the discounts, dispensing fees, administration fee pricing terms available in the market place at time of the market check for plans comparable in size and plan design. The results will be shared with you in a Market Check Report Part A. 1: Agree, 2: Disagree (explain): [ Text ]
47. In addition, the market check will compare the aggregate value of the Manufacturer Payment pricing terms of Commonwealth/DEI with the aggregate value of the Manufacturer Payment pricing terms available in the market place at the time of the market check for plans comparable in size and plan design. The results will be shared with you in a Market Check Report Part B. 1: Agree, 2: Disagree (explain): [ Text ]
48. You will provide comments on the Market Check Report within ten (10) business days of receipt. 1: Agree, 2: Disagree (explain): [ Text ]
49. If Market Check Report Part A and/or Part B indicates current market conditions can yield a 1% or more savings of net plan costs, the parties will use reasonable efforts to find mutual agreement on revised pricing terms and other applicable provisions. 1: Agree, 2: Disagree (explain): [ Text ]
50. If mutual agreement cannot be reached within sixty (60) calendar days from the receipt date of the Market Check Report, Commonwealth/DEI has the right to terminate their agreement without charge or penalty effective the plan year immediately following, upon thirty (30) calendar days prior written notice. 1: Agree, 2: Disagree (explain): [ Text ]
51. If Market Check Report results in revised pricing terms, you will make those revised pricing terms effective within thirty (30) calendar days following written approval from Commonwealth/DEI. All pricing terms will be reconciled on an annual basis regardless of effective date, irrespective of the status of the amendment. 1: Agree, 2: Disagree (explain): [ Text ]
52. You will provide an amendment within ten (10) business days of Commonwealth/DEI's written acceptance of the market check. The amendment must be provided in an unprotected document which can be edited by Commonwealth/DEI. Your turnaround subsequent revisions to the amendment will be no later than five (5) business days from receipt of the requested revisions from Commonwealth/DEI. 1: Agree, 2: Disagree (explain): [ Text ]
| Term and Termination | Format Type | Response | Response | |||
| 53. | The contract is to be effective January 1, 2026 for prescription benefits (plan year plans). | 1: Agree, | ||||
| 2: Disagree (explain): [ Text ] | Question had been updated on v1 and carried over to v2 | |||||
| 54. | January 1, 2026 is to be the contract effective date. Both the contract and benefit plan year will follow a calendar year. | 1: Agree, | ||||
| 2: Disagree (explain): [ Text ] | Question had been updated on v1 and carried over to v2 | |||||
| 55. | Initial Commonwealth/DEI contract term will be for twenty-four (24) months. | 1: Agree, | ||||
| 2: Disagree (explain): [ Text ] | Updated; of note, PBM contracts are typically 3 years | |||||
| 56. | You agree to provide a renewal proposal at least two hundred forty (240) calendar days prior to the contract expiration date. | 1: Agree, |
2: Disagree (explain): [ Text ]
| 57. | Commonwealth/DEI and has the right to terminate the Agreement, with or without cause and without termination charges, with thirty (30) calendar days written notice and Commonwealth/DEI shall be the only party to have termination without cause rights. [Note: KEHP has statutory right of termination for convenience.] | 1: Agree, | ||
| 2: Disagree (explain): [ Text ] | Updated | |||
| 58. | Should you terminate for cause, Commonwealth/DEI and will require one hundred eighty (180) calendar days written notice. | 1: Agree, |
2: Disagree (explain): [ Text ]
59. Upon termination, you agree to pay Commonwealth/DEI and all Manufacturer Payments received within thirty-six (36) months after the end of the agreement, unless termination results from you terming for cause. The payments will follow the contractual cycle. 1: Agree, 2: Disagree (explain): [ Text ]
60. You will be responsible for incurred Claims up to the contract termination date, regardless of paid date. The replacement vendor will have the responsibility to pay Claims incurred after the termination date of the contact. 1: Agree, 2: Disagree (explain): [ Text ]
61. Upon termination of Commonwealth/DEI and 's contract, you will provide all necessary documentation (i.e. plan set-up), Claims files, prescription history, and other data needed for the successful transition of the program to the appointed vendor within a mutually agreed upon reasonable timeframe and at no additional cost to Commonwealth/DEI and . This includes, but is not limited to, all open Mail Order, specialty at Retail (for open specialty network) and specialty pharmacy refills, prior authorization histories, accumulators used in all plan options and at least twelve months of historical Claims data. It is appropriate for the PBM to remove confidential pricing information from this documentation. 1: Agree, 2: Disagree (explain): [ Text ]
62. The Contractor's obligations under this section regarding the security, confidentiality, and ownership of information as set forth in this section shall survive termination of this contract. 1: Agree, 2: Disagree (explain): [ Text ]
63. The provisions of this contract shall be deemed severable, and the unenforceability of any one or more provisions shall not affect the enforceability of any of the other provisions. In addition, if any provision of this contract, for any reason, is declared to be unenforceable, the parties shall substitute an enforceable provision that, to the maximum extent possible in accordance with applicable law, preserves the original intentions and economic positions of the parties. 1: Agree, 2: Disagree (explain): [ Text ]
| 64. | After the initial contract period of two (2) years, any increases to admin fees shall be tied to CPI-U. | 1: Agree, | ||||
| 2: Disagree (explain): [ Text ] | Updated; of note, PBM contracts are typically 3 years | |||||
| Client - General | Format Type | Response | Response | |||
| 65. | Commonwealth/DEI retains the right to audit such information as reasonably required to determine that your firm is complying with the Agreement, which includes but is not limited to: 100% of pharmacy Claims data, with all NCPDP fields from the most current version and release; data management; participating pharmacy contracts with PBM (transparent pricing models only); pharmaceutical manufacturer; Mail Order and Specialty Pharmacy contracts to the extent they exist with other vendor(s); Group Purchasing Organization or aggregator contracts; approved and denied utilization management reviews; clinical program outcomes; appeals; and information related to the reporting and measurement of performance guarantees. | 1: Agree, |
2: Disagree (explain): [ Text ]
66. Each and every payment by Commonwealth/DEI and to the vendor, whether representing fees, Claims or otherwise, would be subject to audit and reconciliation and no such payment made by Commonwealth/DEI and would constitute a waiver of its right to audit or reconcile. 1: Agree, 2: Disagree (explain): [ Text ]
67. Audits may be performed annually, at any time (including the months of November, December, January and February) by the auditor as determined by Commonwealth/DEI. 1: Agree, 2: Disagree (explain): [ Text ]
| 68. | You agree there will be no limit to the number of Claims/discrepancies reviewed by Commonwealth/DEI's auditor and vendor. | 1: Agree, | ||
| 2: Disagree (explain): [ Text ] | Updated | |||
| 69. | Commonwealth/DEI retains the right to audit at no additional charge to them, including no direct pass-through of any data retrieval fees, for up to two years of data. If additional data beyond two years is required for any audit and the data has already been stored, your standard data retrieval fees may be charged. | 1: Agree, |
2: Disagree (explain): [ Text ]
70. Commonwealth/DEI retains the right to perform additional audits of similar scope at no additional charge during the year if requested as a follow-up to ensure significant/material errors found in any prior audit have been corrected and are not recurring, or if additional information becomes available to warrant further investigation. 1: Agree, 2: Disagree (explain): [ Text ]
71. Commonwealth/DEI retains the right to audit more than once per year if the audits are different in scope or for different services. 1: Agree, 2: Disagree (explain): [ Text ]
72. Commonwealth/DEI retains the right to audit up to twenty-four (24) months after the termination of this Agreement. 1: Agree, 2: Disagree (explain): [ Text ]
73. You agree to provide reasonable cooperation with requests for information, which includes but is not limited to the timing of the audit, deliverables, data/information requests and your response time to auditor questions during and after the process. Your firm will also provide a response to all "findings" it receives within 30 calendar days, or at a later date if mutually determined to be more reasonable based on the number and type of findings. To the extent the auditor has follow up questions to your responses, you will acknowledge receipt of the question with 48 hours and provide a formal response with answers to auditors questions within five business days 1: Agree, 2: Disagree (explain): [ Text ]
74. If the audit identifies confirmed errors, you will provide service warranty reports to auditor for every confirmed error. 1: Agree, 2: Disagree (explain): [ Text ]
75. You will review the service warranty with auditor and Commonwealth/DEI for final approval. The service warranty will not be irreversible and will not introduce new methodology to offset amounts due. 1: Agree, 2: Disagree (explain): [ Text ]
76. Issues identified in an external audit will not be used to offset amounts due back to Commonwealth/DEI and or to Members. 1: Agree, 2: Disagree (explain): [ Text ]
77. Commonwealth/DEI shall not be liable for underpayments made as result of PBM error and discovered through the audit. 1: Agree, 2: Disagree (explain): [ Text ]
78. 100% of any agreed to adjustments, payments and/or reimbursements determined to be necessary as a result of any examination or audit shall be paid by you within thirty (30) calendar days after both parties agree with the amounts to be reconciled, as applicable, and have executed an appropriate release document closing the audit period, which can include electronic acknowledgement. 1: Agree, 2: Disagree (explain): [ Text ]
79. You agree to provide Commenwealth/DEI an audit fund of $350,000 per contract year to conduct Benefit, Financial and Rebate audits. 1: Agree, 2: Disagree (explain): [ Text ]
| 80. | You agree to provide Commenwealth/DEI a Pre-Implementation Audit Fund of $100,000 or the amount vendor estimates would be required to complete this audit, based on KEHP's size and complexity. | 1: Agree, | ||||
| 2: Disagree (explain): [ Text ] | Based on experience, PIA audit funds range from $45k - $60k for the big 3 or, PBMs will bake it into the implementation credits; recommend leaving this at $100k | |||||
| 81. | Addtionally, you agree to give Commonwealth/DEI a discount credit of $2,000,000 (Year 1), $1,500,000 (Year 2) and $1,000,000 (Year 3) | 1: Agree, | ||||
| 2: Disagree (explain): [ Text ] | New Question for technical and financial | |||||
| Client Audit Rights - Claim Audits | Format Type | Response | Response | |||
| 82. | You agree to provide de-identified Claims data in a file layout acceptable to Commonwealth/DEI and to perform a Claims audit, at no additional charge. | 1: Agree, |
2: Disagree (explain): [ Text ]
83. Commonwealth/DEI may mutually acceptable independent third party retained by Commonwealth/DEI and may conduct a Claims audit annually and such audits shall be limited to the prior two contract years of data. Commonwealth/DEI retains the right to audit beyond the prior two contract years if a Claims audit indicates a systemic issue. 1: Agree, 2: Disagree (explain): [ Text ]
| Client Audit Rights - Manufacturer Payment Audits | Format Type | Response | Response | |||
| 84. | Commonwealth/DEI through a mutually agreeable independent third party retained by Commonwealth/DEI may conduct an annual Manufacturer Payments audit for the prior two (2) contract years and two (2) years post-termination. For purposes of the Manufacturer Payments audit, the parties agree that Aon or its subcontractor, Caribou, are approved auditors. You agree to allow Commonwealth/DEI to audit no fewer than ten (10) pharmaceutical company contracts and/or a minumum or 60% of the total rebates paid to Commonwealth/DEI for 4 quarters directly related to Commonwealth's Manufactuere Payments as selected by Commonwealth/DEI. Such review of pharmaceutical company contracts may include formulary and Manufacturer Payment provisions and shall be limited to information necessary for validating the accuracy of the Manufacturer Payment amounts remitted to Commonwealth/DEI by your firm. | 1: Agree, | ||||
| 2: Disagree (explain): [ Text ] | See revisions - also added additional requirements based on industry experience | |||||
| 85. | The right to audit Manufacturer Payments extends to any and all agreements between PBM, PBM Affiliates, Group Purchasing Organizations or aggregators, and pharmaceutical manufacturers based on the definition of Manufacturer Payments. This includes but is not limited to Rebate agreements, Manufacturer Payment agreements, and other types of agreements that are held by PBM Affiliates, Group Purchasing Organizations or aggregators, or any entity providing the same or similar services. | 1: Agree, |
2: Disagree (explain): [ Text ]
| 86. | The right to audit the reconciliation of all rebate credits (specialty and non-specialty drugs) and all Average Manufacturer Price (AMP) cap specialty and non-specialty drugs on an annual basis. | 1: Agree, | ||||
| 2: Disagree (explain): [ Text ] | New Question | |||||
| Client Audit Rights - Implementation and Platform Migration Audits | Format Type | Response | Response | |||
| 87. | Commonwealth/DEI reserves the right to conduct 1) a quality review of the plan designs to be loaded in the Claims system(s) prior to implementation (or as soon thereafter as reasonably possible) and 2) a Commonwealth/DEI specific readiness assessment prior to the effective date of the implementation. | 1: Agree, |
2: Disagree (explain): [ Text ]
88. You will provide all necessary support to enable Commonwealth/DEI to review Commonwealth/DEI selected test Claims in a test environment that mirrors the plan information present in the "live" Claims processing system and access your readiness to implement the business without error. 1: Agree, 2: Disagree (explain): [ Text ]
89. You will perform all of the tasks necessary to complete the implementation audit(s) (including follow up test Claims) at least ten (10) calendar days prior to the effective date. This assumes that Commonwealth/DEI has signed off on the benefit set-up by no later than two and a half months prior to the effective date. 1: Agree, 2: Disagree (explain): [ Text ]
90. If you require Commonwealth/DEI to change Claim platforms, you will allow Commonwealth/DEI to conduct a pre-migration readiness assessment and Claim audit in order to test that the set up and benefits will be processed correctly. The cost of the migration audit will be paid for by your organization. 1: Agree, 2: Disagree (explain): [ Text ]
| Liability/Regulatory | Format Type | Response | Response | |
| 91. | Your firm maintains a fidelity bond as required by ERISA. | 1: Agree, |
2: Disagree (explain): [ Text ]
92. Your firm maintains liability coverage with limits not less than $5,000,000 per occurrence and in the aggregate per policy year, with excess liability coverage in the amount not less than $5,000,000 per policy year. Evidence thereof will be furnished to Commonwealth/DEI upon request. 1: Agree, 2: Disagree (explain): [ Text ]
| 93. | Provide level of coverage for each: | |||
| a. | Liability insurance covers: medical management decisions | dollar, 0 | Updated question #91 | |
| b. | Liability insurance covers: professional malpractice | dollar, 0 | ||
| c. | Liability insurance covers: provider contracting | dollar, 0 | ||
| d. | Liability insurance covers: cyber security | dollar, 0 | New Question | |
| 94. | You agree to indemnify and hold Commonwealth/DEI harmless for your negligence or for your failure to perform under the Agreement. Commonwealth/DEI shall not provide any indemnity in favor of your firm. | 1: Agree, |
2: Disagree (explain): [ Text ]
| 95. | Please describe any judgment or settlement during the past three (3) years or pending litigation that could result in judgments or settlements in excess of $100,000. | Text | ||||
| 96. | You agree to PBM services at a fiduciary level of care in favor of the Commonwealth/DEI. | 1: Agree, | ||||
| 2: Disagree (explain): [ Text ] | Question added | |||||
| Member Appeals | Format Type | Response | Response | |||
| 97. | Upon request by Commonwealth/DEI you will perform initial Claims review, first level appeals, and second level appeals on behalf of Commonwealth/DEI. | 1: Agree, |
2: Disagree (explain): [ Text ]
| 98. | Upon request by Client, you will make available and facilitate review by an external or third-party vendor (independent review organization (IRO)). | 1: Agree, | ||
| 2: Disagree (explain): [ Text ] | New Question | |||
| 99. | You will act as a fiduciary for all Claims and appeals and you will facilitate access to external reviews. | 1: Agree, |
2: Disagree (explain): [ Text ]
| Compliance - General | Format Type | Response | Response | |
| 100. | You and your subcontracted vendors will comply with all federally mandated statutes, including but not limited to ERISA, HIPAA and DOL regulations, as applicable, around member services, complaints, appeals, timeliness of responses and confidentiality. Any fines related to non-compliance will be your sole responsibility. | 1: Agree, |
2: Disagree (explain): [ Text ]
101. You maintain a dedicated individual or staff responsible for resolving HIPAA issues. 1: Agree, 2: Disagree (explain): [ Text ]
102. You will notify Commonwealth/DEI of any and all HIPAA violations committed by your organization as soon as the issue is discovered. 1: Agree, 2: Disagree (explain): [ Text ]
103. Your processes, systems and reporting will be in full compliance with federal and state requirements, and compliant with HIPAA for acceptance of Claim transactions in the applicable industry standard NCPDP format. Any fines related to non-compliance will be your sole responsibility. 1: Agree, 2: Disagree (explain): [ Text ]
104. You will provide support for class action settlements and notify Commonwealth/DEI of litigation against your organization. 1: Agree, 2: Disagree (explain): [ Text ]
| 105. | Offshoring any data storage for Commonwealth/DEI is not permitted. | 1: Agree, | ||
| 2: Disagree (explain): [ Text ] | Updated | |||
| 106. | You will abide by and comply with all current and future state and federal laws relevant to Commonwealth/DEI's benefit plan and will prepare all necessary reporting and file on behalf of Commonwealth/DEI if they so desire. | 1: Agree, |
2: Disagree (explain): [ Text ]
107. You will provide any necessary standard file feeds related to current and future rules and regulations at no cost. 1: Agree, 2: Disagree (explain): [ Text ]
108. You will provide all necessary information for Commonwealth/DEI to comply with the Transparency in Coverage and Consolidated Appropriations Act rules and regulations at no cost. 1: Agree, 2: Disagree (explain): [ Text ]
| Compliance – Privacy and Confidentiality | Format Type | Response | Response | |
| 109. | You agree you will not sell Commwealth/DEI's pharmacy data without prior written approval and notice from Commonwealth/DEI and . | 1: Agree, |
2: Disagree (explain): [ Text ]
110. You will adopt and implement written confidentiality policies and procedures in accordance with applicable law to ensure the confidentiality of member information used for any purpose. 1: Agree, 2: Disagree (explain): [ Text ]
| 111. | You will not use or further disclose protected health information (PHI) other than as permitted or required by the Business Associate Agreement (BAA) or as required by law. The BAA for KEHP is attached within Attachment A. | 1: Agree, | ||
| 2: Disagree (explain): [ Text ] | Confirm Exhibit (letter or number) attachment | |||
| 112. | You will use appropriate safeguards to prevent the unauthorized use or disclosure of the PHI, including but not limited to best practices for health industry cybersecurity (e.g.., compliance with Cybersecurity Act of 2015, Section 405(d)), and obtain security audits and certifications as appropriate under best practices for the industry (e.g., SOC 2 Type 2, HITRUST). You will report to Commonwealth/DEI and any unauthorized use or disclosure of the PHI. | 1: Agree, |
2: Disagree (explain): [ Text ]
113. You will mitigate, to the extent practicable, any harmful effect that is known to you of a use or disclosure of PHI by your firm in violation of the requirements of the federal privacy rule. 1: Agree, 2: Disagree (explain): [ Text ]
114. You will provide access to PHI in a "designated record set" in order to meet the requirements under 45 CFR §164.524. 1: Agree, 2: Disagree (explain): [ Text ]
115. You will make any amendment(s) to PHI in a "designated record set" pursuant to 45 CFR §164.526. 1: Agree, 2: Disagree (explain): [ Text ]
116. You will document such disclosures of PHI and information related to such disclosures as would be required to respond to a request by an individual for an accounting of disclosures of PHI in accordance with 45 CFR §164.528. 1: Agree, 2: Disagree (explain): [ Text ]
117. You will (i) implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic PHI that your firm creates, receives, maintains, or transmits, (ii) report to Commonwealth/DEI any security incident (within the meaning of 45 CFR §164.304) of which you become aware, and (iii) ensure that any employee of your firm or agent, including any subcontractor to whom you provide PHI received from, or created or received by your firm agrees to implement reasonable and appropriate safeguards to protect such PHI. 1: Agree, 2: Disagree (explain): [ Text ]
| Compliance - Mental Health Parity | Format Type | Response | Response | |||
| 118. | Upon Commonwealth/DEI request, you shall prepare and provide Commonwealth/DEI a comparative analysis with respect to non-quantitative treatment limitations (and provide any supporting documentation) as required under and consistent with any relevant legislation at no additional charge, in each case, as soon as administratively practicable following Commonwealth/DEI's request but no later than 14 days thereafter. PBM will file on behalf of the Commonwealth/DEI with appropriate regulatory authority, at Commonwealth/DEI's direction and as allowable by law. | 1: Agree, | ||||
| 2: Disagree (explain): [ Text ] | Updated | |||||
| Claims Processing | Format Type | Response | Response | |||
| 119. | What is the name of the adjudication platform you will use for Commonwealth/DEI. | 1: Agree, |
2: Disagree (explain): [ Text ]
| 120. | You agree that all claims will process at a NADAC or WAC price unless there is not a NADAC or WAC price. In the event that there is not a NADAC or WAC price, the claim will process at the lower of logic at the AWP discount price or MAC price or pass through price. | 1: Agree, | ||
| 2: Disagree (explain): [ Text ] | Added question | |||
| 121. | You agree the AWP used to price the Claim must be from only one nationally recognized source (e.g. Medi-Span). | 1: Agree, |
2: Disagree (explain): [ Text ]
| 122. | Confirm that the source above is currently Medi-Span. | Confirm |
| 123. | Confirm your organization is a licensed repackager of prescription drugs. | Confirm |
| 124. | You agree not to charge Commonwealth/DEI a higher AWP price for any repackaged products assigned a new NDC number by a repackager, a manufacturer, or at Mail Order, than the original manufacturer/labeler AWP price for the same product (drug name, form, and strength). | 1: Agree, |
2: Disagree (explain): [ Text ]
125. You agree to reimburse providers for all Claims incurred on or after the effective date of the contract and in accordance with Commonwealth/DEI provisions for the submission of direct Claims for reimbursement. 1: Agree, 2: Disagree (explain): [ Text ]
126. You agree to use the "maintenance medication indicator" provided in a nationally recognized drug information source (e.g., Medi-Span) to identify/define "maintenance medications" for purposes of a mandatory mail program, a program that charges a penalty for refills obtained at Retail pharmacies instead of mail, a traditional Retail 90 program, or a "Mail at Retail" program that allows up to a 90-day supply of maintenance drugs to be dispensed from certain Retail pharmacies with Mail Order-like pricing. 1: Agree, 2: Disagree (explain): [ Text ]
| 127. | You agree not to charge an additional fee for prescriptions that require a coldpack. | 1: Agree, | ||
| 2: Disagree (explain): [ Text ] | New Question - we've noticed the PBMs are charging a coldpack fee of up to $27 per Rx mailed and passing these fees onto the client | |||
| 128. | You will accept Paper Claims from Commonwealth/DEI or their associates for proper adjudication and invoicing. | 1: Agree, |
2: Disagree (explain): [ Text ]
| Specialty Drugs | Format Type | Response | Response | |
| 129. | You will allow Commonwealth/DEI the flexibility to determine if plan Members can fill specialty drug prescriptions at Retail, and will include pricing for a voluntary option (open Retail network/no Retail refill limit) and a closed network options (Retail lockout or Retail refill limit). | 1: Agree, |
2: Disagree (explain): [ Text ]
130. Please include pricing on the "Specialty Drugs" Worksheet.
1: Attached, 2: Not provided
| 131. | Currently, the KY state law prohibits Commonwealth/DEI to have an exclusive Specialty pharmacy arrangement. However, should this KY state law change over the course of the contract term you agree if Commonwealth/DEI elects to use your preferred specialty pharmacy on an exclusive basis, you will not charge for the following: | ||
| a. | Utilization Management (UM) Programs (Prior Authorizations, Quantity Limits, Step Therapy, etc.). | 1: Agree, |
2: Disagree (explain): [ Text ]
b. Medication Adherence Programs. 1: Agree, 2: Disagree (explain): [ Text ]
132. You must provide Commonwealth/DEI with sixty (60) calendar days advance notice of modifications to the list of Specialty Drugs and corresponding pricing terms. 1: Agree, 2: Disagree (explain): [ Text ]
133. In making any such modifications, you will provide Commonwealth/DEI with a revised and complete list noting the effective date for each modification and the rationale for the change. 1: Agree, 2: Disagree (explain): [ Text ]
134. Additions to your Specialty Drug list will be based on the agreed upon criteria for defining Specialty Drugs, unless approved by Commonwealth/DEI. 1: Agree, 2: Disagree (explain): [ Text ]
135. Specialty Drugs will be removed from the Specialty Drug List when they no longer meet the definition of a Specialty Drug. Upon removal from the Specialty Drug List, they will be subject to the pricing for the channel in which they are dispensed. 1: Agree, 2: Disagree (explain): [ Text ]
136. You will allow Commonwealth/DEI to carve out utilization management, including prior authorization to a third party vendor. 1: Agree, 2: Disagree (explain): [ Text ]
137. You will allow Commonwealth/DEI to carve out specialty drug distribution and utilization management to a third party vendor. 1: Agree, 2: Disagree (explain): [ Text ]
138. Within the Specialty offering, you agree to support and maintain a Specialty Drug List that gives Commonwealth/DEI ability to include/exclude HIV and transplant. 1: Agree, 2: Disagree (explain): [ Text ]
| MAC Pricing | Format Type | Response | Response | |
| 139. | You will employ your most aggressive MAC list prices which must include a minimum of 95% of all generic drugs. | 1: Agree, |
2: Disagree (explain): [ Text ]
140. Products will be added to the MAC list no later than twenty-one (21) days after the products becomes available. 1: Agree, 2: Disagree (explain): [ Text ]
141. You will apply the same MAC list at all Retail, Mail Order, and Specialty Pharmacies. Including pharmacies owned by or affiliated with your PBM. 1: Agree, 2: Disagree (explain): [ Text ]
142. In addition, the MAC pricing schedule at Mail Order and (including Specialty Drugs) will include the same or more favorable pricing (i.e. lower per unit prices) than at Retail Pharmacies for every drug. 1: Agree, 2: Disagree (explain): [ Text ]
143. Your MAC pricing schedule at mail will include a comparable list of 300-400 low cost generics included in Retail generic promotion programs at competitive pricing (i.e. pricing will be equal to or less than $10 for a 90-day supply). 1: Agree, 2: Disagree (explain): [ Text ]
144. Effective MAC discounts cannot be lower than non-MAC AWP discounts. 1: Agree, 2: Disagree (explain): [ Text ]
145. Upon request, including for audits, you will provide Commonwealth/DEI a copy of the actual MAC list and pricing schedule. 1: Agree, 2: Disagree (explain): [ Text ]
146. MAC List pricing changes shall adhere to the table on "RX-Pricing, MAC List", however, the annual cumulative maximum change for individual drug prices on the MAC List will be limited to twenty-five percent (25%) increase measured from January 1 of each calendar year. The only exceptions to the maximum are changes outside of PBM control (e.g., drug shortages, pharmacy network appeals). When Commonwealth/DEI conducts an audit pursuant to the agreement, you will provide the auditing party with the justification of pricing changes made outside of the ranges in the table, pursuant to the exceptions listed above. 1: Agree, 2: Disagree (explain): [ Text ]
| Mail Service | Format Type | Response | Response | ||
| 147. | Provide the total number of Mail Order facilities wholly owned and operated by your firm nationwide. (Note that PBM may be required to accept other mail order providers into network as required by Kentucky law, if such provider agrees to all network rules.) | Number | Added | ||
| 148. | Service Statistics for all Mail Order Facilities: | ||||
| a. | Quarterly Dispensing Capacity | Number | |||
| b. | Number of Prescriptions Dispensed in the Most Recent Quarter | Number | |||
| c. | Ratio of Pharmacists to Pharmacy Technicians | 1: Agree, |
2: Disagree (explain): [ Text ]
| d. | Average Number of Prescriptions Dispensed per Pharmacist per Hour | Number | |||
| 149. | Average turnaround time in the most recent quarter for prescriptions that: | ||||
| a. | Required intervention (in days) | Number | |||
| b. | Did not require intervention (in days) | Number | |||
| 150. | You will communicate any delays beyond three (3) calendar days in the delivery of prescriptions to the member. | Yes/No/Explain | |||
| 151. | In the event of a natural disaster or national emergency, you will continue to fill all prescription requests, proactively obtaining any necessary overrides to facilitate this process, and provide Members with expedited delivery to convenient locations. | Yes/No/Explain | |||
| 152. | You will arrange and pay for a short-term Retail supply of a delayed or incorrectly processed Mail Order prescription caused by your organization. In addition, you agree not to charge Members for expedited delivery of the Mail Order prescription if the prescription delay is caused by your organization. | Yes/No/Explain | |||
| 153. | You will assure that 100% of Mail Order prescriptions will be imaged and entered when received at Mail Order (including Specialty prescriptions). You will assure that you will be able to electronically track 100% of all Mail Order prescriptions (Including Specialty) throughout the filling process, on a timely basis, from the point of prescription is received until it is shipped to the member. | Yes/No/Explain | |||
| 154. | You assure that, within twenty-four (24) hours, you will contact prescribers and/or Members via a telephone call or email for 100% of incomplete Mail Order prescriptions (including Specialty) that require additional information. | Yes/No/Explain | |||
| 155. | You will provide both email and telephone voicemail capabilities to communicate to Members their Mail Order has been received and the date the order has been shipped to Members. | Yes/No/Explain | |||
| 156. | You will have the capability to accept early refill orders and suspend or “queue” these orders in your system until the earliest refill date for processing. | Yes/No/Explain | |||
| 157. | You will have the capability to accept major credit cards and store credit card number(s) by Member account for future Mail Order prescriptions. You will advise Members thirty (30) days in advance of the date their credit card number is going to expire. | Yes/No/Explain | |||
| 158. | If requested, you will provide Members with checks for monies owed to them instead of maintaining credits at your Mail Order facility. | Yes/No/Explain | |||
| 159. | Can you support a floor limit of $300 for accepting prescription orders from Members without the correct payment? | Yes/No/Explain | |||
| 160. | Members will not be billed for copayments greater than $500 without first contacting them to advise them of their copayment. | Yes/No/Explain | Question had been rephrased on v1 and carried over to v2 | ||
| 161. | Commonwealth/DEI will not be required to pay outstanding balances owed by Membership. | Yes/No/Explain | |||
| 162. | Commonwealth/DEI shall have the right to advise you in writing to change the floor limit for all Members or just those with unpaid balances after one hundred twenty (120) calendar days of dispensing. | Yes/No/Explain | |||
| 163. | You will not require Commonwealth/DEI to mandate use of the Mail Order Pharmacies. | Yes/No/Explain | |||
| 164. | If requested, you will provide a toll-free number to Members currently using the incumbent's Mail Order facility for the sole purpose of furnishing the information necessary to transition prescriptions to your firm. | Yes/No/Explain | |||
| 165. | If a Mail Order package is lost, stolen or not delivered, you will not charge Commonwealth/DEI or the plan participant for the Mail Order Drug. | Yes/No/Explain | |||
| 166. | If requested, you are willing and able to prorate copays at Mail Order for Claims that are processed for less than or equal to a sixty (60) Day Supply. | Yes/No/Explain | |||
| 167. | If requested, you are willing and able to allow members to make three payments for a ninety (90) Day Supply on drug costs or copayments at Mail Order for Claims. | Yes/No/Explain | |||
| 168. | You shall not charge Commonwealth/DEI any mark-up on shipping costs nor retain any margin on shipping product. | Yes/No/Explain | |||
| 169. | PBM does not use dispensing facilities or process prescriptions outside the United States. | Yes/No/Explain | Question had been rephrased on v1 and carried over to v2 | ||
| 170. | You will allow a second address to be added for mailing Home Delivery prescriptions if different from permanent address (i.e. not just a temporary one-time address). | Yes/No/Explain | |||
| 171. | Does your network currently include standalone cost-plus pharmacies. If no, are you willing to add cost-plus pharmacies to your network prior to implementation? | Yes/No/Explain | Moved question from Copay Offset Savings Programs - more appropiate here since it's a mail order program | ||
| 172. | Does your PBM allow Mark Cuban's Cost Plus Drugs (MCCPD) in your network? If no, are you willing to add MCCPD to your network? | Yes/No/Explain | Added question specific to MCCPD since the big 3 have an issue with including in their network [Strike pert mtg discussion] | ||
| Specialty Pharmacy Services | Format Type | Response | Response | ||
| 173. | Provide the total number of Specialty Pharmacy facilities wholly owned and operated by your firm nationwide. | Number | |||
| 174. | Service Statistics for all Specialty Pharmacies: | ||||
| a. | Quarterly Dispensing Capacity | Number | |||
| b. | Number of Prescriptions Dispensed in the Most Recent Quarter | Number | |||
| c. | Ratio of Pharmacists to Pharmacy Technicians | 1: Agree, |
2: Disagree (explain): [ Text ]
| d. | Average Number of Prescriptions Dispensed per Pharmacist per Hour | Number | ||||
| 175. | Average turnaround time in the most recent quarter for prescriptions that: | |||||
| a. | Required intervention (in days) | Number |
This is the start of the file's text. The full file is on GovTribe.
File details come from the government source that posted it. Updated .