Attachment_C_-_26-0408-RFP_PBM_RFP_Questionaire.xlsx
XLSX spreadsheet 431 KB Posted
- Attached to
- 26-0408-RFP Pharmacy Benefit Manager Services
- Solicitation number
- 26-0408-REQ
- Issued by
- Pinellas County, Florida
About this file
Summary of RFP 26-0408 Pharmacy Benefit Manager Services
This is a comprehensive Request for Proposal questionnaire and financial requirements document issued by the Pinellas County Board of County Commissioners for Pharmacy Benefit Management (PBM) Services covering approximately 5,726 plan members across the county. The RFP seeks a qualified PBM vendor to provide full-service pharmacy benefit management including claims processing, mail order and specialty pharmacy dispensing, clinical management programs, member services, retail network management, and fraud, waste, and abuse programs. The contract term is five years with optional two-year renewal periods, with an effective date of January 1, 2027. Proposers must be licensed PBMs in all 50 states, manage at least one million Rx lives, and have a minimum of eight years of experience as a full-service PBM. The questionnaire requests detailed information across multiple categories including general company information, account management capabilities, member services infrastructure, clinical management programs, retail and mail order network details, systems and technology capabilities, implementation procedures, audit rights, and performance guarantees.
The financial proposal must include pricing on a per-net-paid-claim basis for all delivery channels including retail (1-83 days' supply), retail 90-day supply, mail order, retail specialty, and PBM specialty pharmacy services across all five contract years. The RFP specifies that pricing can be submitted as either traditional or pass-through arrangements, with detailed guarantees required for brand and generic drug discounts, dispensing fees, and minimum rebate amounts by delivery channel. All financial guarantees must be reconciled and paid within 90 days annually for discounts and dispensing fees, and within 180 days for rebates, with vendors assuming dollar-for-dollar risk on any shortfalls. The incumbent vendor is Express Scripts Inc. (ESI). The RFP requires vendors to demonstrate compliance with specific exclusions and inclusions for rebate guarantees, account for expected biosimilar shifts and WAC decreases, and provide performance guarantees covering implementation satisfaction, account management, member services metrics, and financial reconciliation timelines.
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Cover Page
Pinellas County Board of County Commissioners
| Request for Proposal |
| for |
| Pharmacy Benefit Management Services |
Background
| Pinellas County Board of County Commissioners |
| Pharmacy Request for Proposal: Background |
| Client Name: | Pinellas County Board of Commissioners |
| Segment Type: | Employer |
| Incumbent PBM Vendor: | Express Scripts Inc (ESI) |
| Geographic Location (Headquarters): | Pinellas County, FL |
| About CLIENT | Pinellas County Board of County Commissioners - Pinellas County |
| Total Relevant Plan Members: | 5,726 |
| Plan Design and Clinical Rules: | To be provided upon receipt of vendor's Intent to Bid |
| Claims Data File: | To be provided upon receipt of vendor's Intent to Bid |
| Effective Date Requested: | 1/1/27 |
| Contract Term Requested: | 5 years with option for 2 year renewal |
| Formulary Requested: | Exclusionary |
| Pricing Format Requested: | Pass-Through |
| Specialty Arrangement Requested: | Open |
| Retail 90 Pricing Requested: | Narrow Retail 90, only includes WAG, all others excluded |
| Network Requested: | Broad |
&"-,Bold"&KFF0000CONFIDENTIALITY NOTICE: This document and all associated documents are proprietary and confidential, and are not intended for distribution outside of your organization.
&P &A &G https://pinellas.gov/pinellas-county-board-of-county-commissioners/ RFP Rules
| Pinellas County Board of County Commissioners |
| Pharmacy Request for Proposal: RFP Rules |
| Instructions: Complete all light blue shaded cells in this document. It is strongly encouraged that your organization agree with each item. |
| Failure to do so could materially impact the scoring of your RFP response, and may potentially disqualify your bid at CLIENT's discretion. |
| If “Yes” is selected, no further explanation is needed. Do NOT change font color so that responses will be seen in the black-filled cell or write in cells outside of the RFP table. |
| These responses will not be considered in the evaluation of your proposal. |
| RFP Rules | PBM Response | ||
| (Yes, No) | Explanation |
(If "No") 1 Do you agree that information provided in accordance with this RFP is the only information that may be submitted as part of your offer?
| 2 | You agree that all correspondence regarding this RFP shall be done exclusively through this OpenGov Solicitation and under no circumstance will CLIENT and/or its Board Members be contacted directly, unless directed otherwise. Failure to adhere to this requirement may result in disqualification of your bid. |
| 3 | The general information contained in this RFP is complete and accurate to the best knowledge of CLIENT. However, the information contained in this RFP and any data provided to you are representations and estimated quantities only and not warranties of CLIENT. All information contained herein is deemed confidential. Each company submitting a proposal shall assume sole responsibility for reliance upon information included in this RFP, and neither CLIENT nor GPP shall have any liability for any inaccuracy contained herein. |
| 4 | In accepting proposals, CLIENT reserves the right to reject any and all proposals and to take the actions which it deems in its sole discretion to be in its best interest. CLIENT is not obligated to accept any response, or the lowest-cost response, to this RFP. This RFP does not obligate CLIENT to pay any costs incurred by you in responding to this RFP. Further, this RFP does not obligate CLIENT to accept or contract for any expressed or implied services. |
| 5 | Ensure all tabs with responses are Print Ready. |
&KFF0000CONFIDENTIALITY NOTICE: This document and all associated documents are proprietary and confidential and are not intended for distribution outside of your organization.
&"-,Italic"Confidential &A &P
Terms and Definitions
| Pinellas County Board of County Commissioners |
| Pharmacy Request for Proposal: Terms and Definitions |
| Instructions: Complete all light blue shaded cells in this document. It is strongly encouraged that your organization agree with each item. |
| Failure to do so could materially impact the scoring of your RFP response, and may potentially disqualify your bid at CLIENT's discretion. |
| If "No" is selected, provide a specific reason in the additional column as to why the definition is not agreed upon. |
| Pasting in your organization’s standard contract definitions is not an acceptable response and will be returned to your organization to respond to as requested. |
| If "Yes" is selected, no further explanation is needed. Do NOT change font color so that responses will be seen in the black-filled cell or write in cells outside of the RFP table. |
| These responses will not be considered in the evaluation of your proposal |
| Term | Definition | PBM Response | ||
| (Yes, No) | Explanation |
(If "No")
| 1 | 100% Member Paid Claims | "100% Member Paid Claims" shall mean claims for Covered Products that are paid 100% by the member outside of the deductible phase. For clarification purposes, claims that applied towards member deductibles shall not be considered 100% member paid claims. |
| 2 | 100% Member Paid Program Claims (e.g., Discount Card) | "100% Member Paid Program Claims" shall mean claims for Covered Products that are dispensed under a Discount Card, or other like program, operated outside of the vendor or has no affiliation with the vendor. |
| 3 | 340B Eligible Claim | “340B Eligible Claim” shall mean a claim for a Covered Product that meets the requirements as defined by the Public Health Service Act and submitted with a submission clarification code of 20 and contracted pharmacies which are categorized as Type 39 or Type 38. Not all claims from covered entities and contracted covered entities are eligible, unless the claim is identified specifically as a 340B Eligible Claim via reconciliation and audit trail. |
Your organization’s definition of “340B Eligible Claim” MUST be consistent for all purposes including, but not limited to, discount and dispensing fee guarantee reconciliation and rebate guarantee reconciliation.
| 4 | Administrative Fee | "Administrative Fee" shall mean the amount per final net paid claim, if any, payable to the vendor for the performance of services. Administrative fees are exclusive and separate from any ingredient cost dispensing fees, pharmacy related fees, ancillary service fees, or optional service fees, if any, payable to the vendor. |
| 5 | Authorized Generics | "Authorized Generics" shall mean prescription drugs that are produced by an innovator (i.e., the brand manufacturer) under a New Drug Application (NDA), or licensed to be produced by a generic company under the New Drug Application (NDA), and are marketed, sold and/or distributed as generics under private label. Further, an Authorized Generic is identical to its brand counterpart in dosage form, safety, strength, route of administration, intended use, active and inactive ingredients and, as applicable, size, shape, color, taste, smell and mouth feel. |
| 6 | AWP | "Average Wholesale Price" or "AWP" shall mean the “average wholesale price” for a Covered Product based on the most current pricing information published by MediSpan for the date and time the Covered Product is dispensed by the pharmacy. The AWP of a Covered Product will be the AWP unit price as published by MediSpan for the 11 digit NDC. Vendor shall not allow adjudication of NDCs of licensed re-packagers where the data source identifies the licensed re-packagers AWP is greater than the original pharmaceutical AWP. Vendor shall update AWP data no less than weekly. |
| 7 | Biosimilars | "Biosimilars" shall mean a type of biological product that is licensed (i.e., approved) by the Food and Drug Administration (FDA) because the product is highly similar to an already FDA-approved biological product, known as the reference product, and has been shown to have no clinically meaningful differences from the reference product. Biosimilars shall also include an “interchangeable biological product” which, in addition to meeting the biosimilarity standard, is expected to produce the same clinical result as the reference product in any given patient. Biosimilars are determined by the FDA from time to time and are listed in the FDA’s Purple Book (presently found at: https://purplebooksearch.fda.gov/ ) |
Biosimilars are Brand Drugs, unless they are required to be classified as Generic Drugs under CMS regulations or FDA standards.
| 8 | Brand Drug | "Brand Drug" shall mean a Covered Product that is defined by MediSpan as a “M”, "N", "O", with exception of Authorized Generics. When a drug is classified as a Brand Drug, it shall be considered a Brand Drug for the purposes of measuring and reconciling financial guarantees. |
| 9 | Claims | "Claims" shall mean those claims processed for payment for Eligible Members. |
| 10 | COB (Secondary Payor) Claim | “COB (Secondary Payor ) Claim” shall mean a claim which processed with an Other Coverage Code of 2 or 8 indicating that the Client is the secondary payer. |
| 11 | Compound Drug | "Compound Drug" shall mean a claim where two or more solid, semi-solid, or liquid medications are mixed together. The end product must not be available in an equivalent commercial form. The product will not be considered a Compound Drug if it is reconstituted or if, to the active ingredient, only water, alcohol, flavoring, coloring, or sodium chloride solutions are added. Compound Drugs shall be priced using the NCPDP D.0 standard which shall capture each ingredient used in the medication. |
| 12 | Controlled Substance | "Controlled Substance" shall mean products with the MediSpan Controlled Substance Code: 2, 3, 4, or 5 |
| 13 | Covered Product | “Covered Product” shall mean those prescription drugs, supplies, devices, and any other related products or services, and other items that are covered under the plan, each as indicated as covered on the vendor's Client set-up forms. For avoidance of doubt, this shall include OTCs and Vaccines. |
| 14 | COVID Testing | “COVID Testing” shall mean products with the MediSpan GPI-8 codes: 94101024, 94101025, 94101026 |
| 15 | COVID Treatment | “COVID Treatment” shall mean products with the MediSpan GPI-8 codes: 12700046, 12700080, 19502080, 19502020, 19502022, 19502025, 19502030, 19502035 or drug name PAXLOVID |
| 16 | COVID-19 Vaccine | “COVID Vaccine” shall mean products with the MediSpan GPI-8 codes: 17100002, 19509902, 19502063 |
| 17 | Custom Formulary | "Custom Formulary" shall mean the list of pharmaceutical products and supplies, quantity limits, prior authorization guidelines, and clinical guidelines for detailing coverage of such products, which is developed and approved by the Client's Pharmacy and Therapeutics (P&T) Committee. |
| 18 | Dedicated | "Dedicated" shall mean those vendor employees or resources that are 100% of the time working on the Client's services. |
| 19 | Designated | "Designated" shall mean those vendor employees and resources that must prioritize work for the Client's services. |
| 20 | Delivery Channel | "Delivery Channel" shall mean Retail 30, Retail 90, Retail Specialty, Mail, and Mail Specialty, individually, for example. |
| 21 | Diabetic Supplies | "Diabetic Supplies" shall mean products with the MediSpan GPI-6 code 972020*. |
| 22 | Diabetic Test Strips | "Diabetic Test Strips" shall mean products with the MediSpan GPI codes 94100030006020 and 94100030006100 only. |
| 23 | Dispensing Fee | "Dispensing Fee" shall mean the service fee or amount payable to a pharmacy to cover the cost of dispensing a Covered Product. The Dispensing Fee is added to the discounted AWP or MAC. No Dispensing Fee is added to the U&C. |
| 24 | Eligible Member | "Eligible Member" shall mean a person covered under any of the Client's prescription drug plans. |
| 25 | Eligible Member Cost Share | "Eligible Member Cost Share" shall mean the amount which an Eligible Member is required to pay for a Covered Product in accordance with the plan design. Eligible Member Cost Share includes any coinsurance (the percentage or portion of the cost of care or service that an Eligible Member may be obligated to pay for a Covered Product at the time the care and/or service is provided), copayment/ copay (the fixed dollar amount that an Eligible Member may be obligated to pay for a Covered Product at the time the Covered Product is provided), or deductible (the amount of out-of-pocket expenses that an Eligible Member is responsible to pay for Covered Product prior to being eligible to receive benefits from the Client’s prescription drug plan). |
| 26 | Flu Vaccine | “Flu Vaccine” shall mean a claim for a Covered Product within the MediSpan Drug Group of Vaccines or Toxoids that is administered for Influenza. |
| 27 | Formulary | "Formulary" shall mean the list of pharmaceutical products and supplies, quantity limits, prior authorization guidelines, and clinical guidelines for detailing coverage of such products. For Medicare Part D, the "Formulary" is developed and approved by the vendor's P&T Committee and adopted by the Client. For Medicaid and Commercial lines of business, the "Formulary" may be developed and approved by the vendor's P&T Committee and/or the Client's P&T Committee. |
| 28 | Generic Drug | "Generic Drug" shall mean a Covered Product as defined by MediSpan as a “Y”. Generic Drugs also shall include Brand Drugs that are treated as “house” generic drugs (dispense-as-written (DAW) 5) by the pharmacy, Single Source Generic Drugs, and Authorized Generics. When a drug is classified as a Generic Drug, it shall be considered a Generic Drug for the purposes of measuring and reconciling financial guarantees. |
| 29 | Hep-C | "Hep-C" shall mean a product within the MediSpan Drug Class of Hepatitis Agents. |
| 30 | Ingredient Cost | "Ingredient Cost" shall mean the component of the price that represents the cost of the Covered Product, excluding the Dispensing Fee and taxes. |
| 31 | Inflammatory Conditions | "Inflammatory Conditions" shall mean products with the MediSpan GPI-8 codes 66290030*, 66270015*, 66270040*, 52504070*, 90250585*. |
The GPI-8 codes listed in this definition are not meant to capture a comprehensive drug group/class, but rather a specific subset of drugs. Includes biosimilars.
32 Insulins "Insulins" shall mean products with the MediSpan GPI-4 code 2710*.
Includes biosimilars.
| 33 | Limited Distribution Drug (LDD) | "Limited Distribution Drug" or "LDD" shall mean a Specialty Drug that is used to treat conditions affecting only a small group of patients across several disease states, (i.e., oncology, growth hormone treatments, and multiple sclerosis) and refers to injectable, infusion, and other specialty products, whose dispensing is restricted by the pharmaceutical manufacturer to only 3 or fewer pharmacies. |
| 34 | Limited Distribution Drug (LDD) Pharmacy | "Limited Distribution Pharmacy" or "LDD Pharmacy" shall mean a licensed pharmacy authorized by pharmaceutical manufacturer to dispense the LDD injectable, infusion, and other specialty products. |
| 35 | Mail Order Pharmacy | "Mail Order Pharmacy" shall mean a duly licensed pharmacy that primarily dispenses prescriptions (but not primarily Specialty Products) through mail delivery service that is contracted with and/or owned or operated by the vendor. |
| 36 | Maximum Allowable Cost (MAC) | "Maximum Allowable Cost" or "MAC" shall mean the unit price that has been established by the vendor for a Brand Drug or Generic Drug included on the vendor's MAC list, which may be amended from time to time by the vendor. |
| 37 | Medical Devices and Supplies | "Medical Devices and Supplies" shall mean products within the MediSpan Drug Group of Medical Devices and Supplies. |
| 38 | NDC-11 | "NDC-11" shall mean the full National Drug Code. |
| 39 | New to Market | "New to Market" shall mean a Brand Covered Product that has been on the market for no longer than 180 days, as of the effective date in MediSpan. |
| 40 | Non Formulary Brand Drugs | "Non Formulary Brand Drug" shall mean the drugs that are not included in the list of preferred medications and/or not included in the drug list approved by the Client. When a drug is identified as a Non-Formulary Brand Drug, it shall be considered a Non-Formulary Brand Drug for all purposes, including Eligible Member Cost Share, therapeutic classification, pricing and all related guarantees. |
| 41 | Non Standard Retail Pharmacies (LTC, Infusion, ITU) | "Non Standard Retail Pharmacies" shall include, but not be limited to, Long Term Care, Home Infusion, Indian/Tribal/Urban (I/T/U), or VA pharmacies. |
| 42 | Other Vaccine | “Other Vaccine” shall mean products with the MediSpan GPI-8 codes: 19509902, 19502063 or with the MediSpan GPI-4 codes: 1710, 1720, 1799, 1899 |
| 43 | Over-the-Counter (OTC) | "Over-the-Counter" or "OTC" shall mean products that are identified by MediSpan RXOTC Indicator as OTC. |
| 44 | Paper Claim | “Paper Claim” shall mean a manual/paper claim submitted by an Eligible Member for Covered Product dispensed by a pharmacy for which the Eligible Member paid cash. |
| 45 | PCSK9 | "PCSK9s" shall mean a product within MediSpan GPI-4 of 3935 |
| 46 | Prescription Drug Services | "Prescription Drug Services" shall mean those Covered Products and related services, which are prescribed by a prescriber and dispensed, furnished or administered to Eligible Members by pharmacies or other authorized health care providers. |
| 47 | Pricing Component | “Pricing Component” shall mean brand discounts, generic discounts, brand dispensing fees, and generic dispensing fees. |
| 48 | Rebates | "Rebates" shall mean, and include, the components as agreed below that are attributable to Covered Products dispensed to its Eligible Members, regardless of whether such amounts are collected by PBM or its GPO/subcontractors. |
| Base | ||
| Incentive | ||
| Portfolio | ||
| Market Share | ||
| Price Protection | ||
| Manufacturer Administrative Fees | ||
| Value-based Remuneration | ||
| Indication-based Remuneration | ||
| Specify any other monies collected by vendor (or its affiliates, intermediaries, or rebate aggregators) for the Client from various pharmaceutical companies. | ||
| 49 | Retail Network Pharmacy | "Retail Network Pharmacy" shall mean any licensed pharmacy, including retail pharmacies, I/T/U pharmacies, pharmacies operated by federally qualified health centers and rural health centers, Long Term Care pharmacies, and Home Infusion pharmacies with which the vendor has contracted to participate in one or more pharmacy networks. Mail Order Pharmacies and Specialty Network Pharmacies are not considered Retail Network Pharmacies. |
| 50 | Single Source Generic Drugs (SSGs) | "Single Source Generic Drugs" or "SSGs" shall mean those Generic Drugs that are only available from one manufacturer and labeler, including generics with limited availability, exclusivity, or competition, including Authorized Generics . When a drug is identified as Single Source Generic Drug, it shall be considered a Single Source Generic Drug for all purposes, including Eligible Member Cost Share, therapeutic classification, pricing and all related guarantees. |
| 51 | Specialty Drug | "Specialty Drug" shall mean a Covered Product that: (a) is injected, infused, orally or topically administered, or inhaled for the ongoing treatment of complex, chronic conditions; (b) requires extensive patient education, risk assessment, mitigation strategies, and/or clinical monitoring; (c) may require temperature-controlled shipping or other special handling and careful adherence to treatment; and (d) meets CMS Requirements for placement on the specialty tier of a Medicare Formulary, if applicable. When a drug is identified as Specialty Drug, it shall be considered a Specialty Drug for all purposes, including Eligible Member Cost Share, therapeutic classification, pricing and all related guarantees. |
| 52 | Specialty Drug List | "Specialty Drug List" shall mean an agreed upon list of Specialty Drugs. |
| 53 | Specialty Network Pharmacy | "Specialty Network Pharmacy" shall mean a pharmacy network or individual pharmacy that primarily dispenses Specialty Drugs and provides specialty services. |
| 54 | Subrogation Claim | “Subrogation Claim” shall mean a claim submitted by any state or a person or entity acting on behalf of a state under Medicaid or similar United States or state government health care programs, for which the Client is deemed to be the primary payor by operation of applicable federal or state laws. |
| 55 | Usual and Customary Price (U&C) |
| "Usual and Customary" or "U&C" shall mean the lowest price, including any Dispensing Fee, a pharmacy would charge a customer without any insurance coverage if such customer were paying cash for the identical drug on the date dispensed. This includes any applicable discounts, including but not limited to, senior discounts, frequent shopper discounts, and other special discounts offered to customers. | ||
| 56 | Zero Balance Claim or Zero Balance Due | "Zero Balance Claim" or "Zero Balance Due" shall mean a claim for which there is no balance due from the Client following the application of the Eligible Member Cost Share to the cost of the claim. |
&KFF0000CONFIDENTIALITY NOTICE: This document and all associated documents are proprietary and confidential and are not intended for distribution outside of your organization.
&"-,Italic"Confidential &A &P
Questionnaire
| Pinellas County Board of County Commissioners |
| Pharmacy Request for Proposal: Questionnaire_Full |
| Instructions: Complete all blue shaded cells in this document. Use the drop-down options where available. To add |
| comments or explanations to a drop-down response, select the cell and press F2. Any comments or explanations included |
| in your response must be limited to 750 characters or less for each cell. |
| # | CATEGORY | QUESTION | BIDDER RESPONSE | |||
| General Information | Exhibit - <Vendor Name> - Executive Summary Memo. | |||||
| Provide a high level summary of what differentiates your company, along with how you feel you can manage CLIENT's program and drug trends. You may include examples based on CLIENT-specific data if you wish, but no items that would be considered contract terms should be qualified in this document. | Include as Exhibit | |||||
| 1. | General Information | Your Company Name | ||||
| 2. | General Information | Who will serve as the primary contact within your organization for correspondence related to this RFP process? | ||||
| x | a | 2. (a) | General Information | Primary RFP Contact Name | ||
| x | b | 2. (b) | General Information | Primary RFP Contact Title | ||
| x | c | 2. (c) | General Information | Primary RFP Contact City, State | ||
| x | d | 2. (d) | General Information | Primary RFP Contact Email | ||
| x | e | 2. (e) | General Information | Primary RFP Contact Phone Number (Office) | ||
| x | f | 2. (f) | General Information | Primary RFP Contact Phone Number (Mobile) | ||
| 3. | General Information | Who will serve as your authorized signatory for this RFP process, with executive-level authority to confirm or modify the details of your proposal? | ||||
| x | a | 3. (a) | General Information | Authorized Signatory/Representative Name | ||
| x | b | 3. (b) | General Information | Authorized Signatory/Representative Title | ||
| x | c | 3. (c) | General Information | Authorized Signatory/Representative City, State | ||
| x | d | 3. (d) | General Information | Authorized Signatory/Representative Email | ||
| x | e | 3. (e) | General Information | Authorized Signatory/Representative Phone Number | ||
| 4. | General Information | Your Company Headquarters Street Address | ||||
| 5. | General Information | Your Company Headquarters City, State, ZIP | ||||
| 6. | General Information | Company State of Incorporation | ||||
| 7. | General Information | Brief Description of Ownership (Public, Private, Not-for-Profit, etc.) | ||||
| 8. | General Information | Total number of employees (US-based) Enter number only. | ||||
| 9. | General Information | Total number of employees (Global) Enter number only. | ||||
| 10. | General Information | Within the last 18 months, has your organization been involved in any transaction or discussions to acquire, be acquired by or affiliate with another business entity? If so, indicate the nature and timing of the transaction, and the relevant entities involved. | ||||
| x | a | 10. (a) | General Information | If so, indicate the nature and timing of the transaction, and the relevant entities involved. | ||
| 11. | General Information | Is your organization currently involved in any lawsuit or other legal proceeding that may materially impact your ability to provide PBM services to CLIENT? If so, provide a brief explanation. | ||||
| x | a | 11. (a) | General Information | If so, provide a brief explanation. | ||
| x | b | 11. (b) | General Information | Are any of the directors on your corporate board affiliated with, employed by, or otherwise compensated by a pharmaceutical manufacturer, retail pharmacy chain, or specialty pharmacy? | ||
| 12. | General Information | Are any of your organization's operations located off shore? If so, describe the area and function they perform and provide the location. | ||||
| 13. | General Information | Confirm that your organization will NOT offshore any services that will be applied to CLIENT. | ||||
| 14. | General Information | Explain how your organization will continuously simplify administrative efforts for CLIENT during the implementation and moving forward? | ||||
| 15. | General Information | Briefly summarize any accreditations or certifications earned by your organization within the last 12 months. | ||||
| 16. | General Information | Briefly summarize any accreditations or certifications that have not been awarded to your organization over the last 12 months, along with the reasons why. | ||||
| 17. | General Information | Has your organization earned any national accreditations for each of the following services (i.e. URAC, NCQA, CPPA, ACHC, CHAP, PCAB, etc.)? If so, list them. | ||||
| x | a | 17. (a) | General Information | Pharmacy Benefit Management | ||
| x | b | 17. (b) | General Information | Mail Service Pharmacy | ||
| x | c | 17. (c) | General Information | Specialty Pharmacy | ||
| x | d | 17. (d) | General Information | Infusion Pharmacy | ||
| x | e | 17. (e) | General Information | Ambulatory Infusion Center | ||
| x | f | 17. (f) | General Information | Infusion Nursing | ||
| x | g | 17. (g) | General Information | Drug Therapy Management | ||
| x | h | 17. (h) | General Information | Prospective/Concurrent UM | ||
| x | i | 17. (i) | General Information | Retrospective UM | ||
| x | j | 17. (j) | General Information | Long Term Care Pharmacy | ||
| x | k | 17. (k) | General Information | Pharmacy Compounding | ||
| x | l | 17. (l) | General Information | Case Management | ||
| x | m | 17. (m) | General Information | Transitions of Care Designation | ||
| x | n | 17. (n) | General Information | Health and Wellness | ||
| x | o | 17. (o) | General Information | Telehealth | ||
| x | p | 17. (p) | General Information | DMEPOS | ||
| x | q | 17. (q) | General Information | Other (specify) | ||
| 18. | General Information | Does your organization use a subcontractor or third party for each of the following services. If so, list the name of the sub-contractors or third parties used. |
If your PBM has executed contracts with multiple subcontractors for the same function (for example, two or more mail order pharmacies), identify the subcontractor that you intend to utilize in connection with providing services to CLIENT.
| x | a | 18. (a) | General Information | Claims adjudication platform |
| x | General Information | If yes, list the name of sub-contractors or third party used | ||
| x | b | 18. (b) | General Information | Member service call center |
| x | General Information | If yes, list the name of sub-contractors or third party used | ||
| x | c | 18. (c) | General Information | Mail order (non-specialty) dispensing |
| x | General Information | If yes, list the name of sub-contractors or third party used | ||
| x | d | 18. (d) | General Information | Mail order specialty dispensing |
| x | General Information | If yes, list the name of sub-contractors or third party used | ||
| x | e | 18. (e) | General Information | Rebate management/aggregation |
| x | General Information | If yes, list the name of sub-contractors or third party used | ||
| x | f | 18. (f) | General Information | Utilization management |
| x | General Information | If yes, list the name of sub-contractors or third party used | ||
| x | g | 18. (g) | General Information | Retail network management |
| x | General Information | If yes, list the name of sub-contractors or third party used | ||
| x | h | 18. (h) | General Information | Independent review organization (IRO) |
| General Information | If yes, list the name of sub-contractors or third party used | |||
| x | i | 18. (i) | General Information | Medication Therapy Management (MTM) |
| x | General Information | If yes, list the name of sub-contractors or third party used | ||
| x | j | 18. (j) | General Information | Other (specify) |
| x | k | General Information | If yes, list the name of sub-contractors or third party used | |
| 19. | General Information | Aside from the subcontractors or third parties identified in the previous questions, list any other subcontractors or third parties that your organization uses and the type of PBM-related services that they provide to your clients. | ||
| 20. | General Information | Will your organization subcontract the delivery of any goods or services for CLIENT? If so, confirm the following: | ||
| x | a | 20. (a) | General Information | Your organization will assume responsibility for its performance in the delivery of goods and services to CLIENT, including the performance of any subcontractor. |
| x | b | 20. (b) | General Information | Your organization will be the sole point of contact with regard to contractual matters related to subcontracted services, unless CLIENT indicates otherwise. |
| x | c | 20. (c) | General Information | Your organization will be fully responsible for any contractual default to CLIENT caused by a subcontractor, just as if your organization itself had caused the default. |
| x | d | 20. (d) | General Information | You will be fully responsible for time or miscellaneous costs incurred by your organization in association with an audit including, but not limited to, the costs associated with providing audit reports, systems access or space. |
| x | e | 20. (e) | General Information | Your organization will be solely responsible for satisfying any claims of its subcontractors for any suspension or termination and will indemnify CLIENT for any liability to them. |
| x | f | 20. (f) | General Information | Each subcontractor will hold CLIENT harmless for any damage caused to them from a suspension or termination and will look solely to your organization for any compensation to which they may be entitled. |
| 21. | General Information | What is the annual and per occurrence limit on the insurance carried to cover claims resulting from negligence, willful acts, errors, omissions, contract breach or violation of law? | ||
| 22. | General Information | What was your total claims volume, in processed claims, for the most recent full calendar year? | ||
| 23. | General Information | What was the total dollar value in rebates and all other pharmaceutical company payments that your organization received in the most recent full calendar year? | ||
| 24. | General Information | How big is your largest Non-MCO Commercial contract, in number of covered member lives? | ||
| 25. | General Information | What is the total number of Non-MCO Commercial contracts with greater than 20,000 covered member lives? | ||
| 26. | General Information | How many unique non-MCO clients (measured in number of individual contracts) were implemented with a January 1, 2024 effective date? | ||
| 27. | General Information | How many total covered non-MCO member lives were implemented with a January 1, 2024 effective date? | ||
| 28. | General Information | Does your organization provide rebate management or rebate aggregation services to any other PBMs? If so, respond to the following questions. | ||
| x | a | 28. (a) | General Information | How many third parties does your organization service in this capacity? Enter number only. |
| x | b | 28. (b) | General Information | Approximately how many member lives are represented by your rebate management and rebate aggregation services, in the aggregate (including your own membership and third party membership)? Enter number only. |
| 29. | General Information | Does your organization own or operate any business units or entities that provide services other than those directly related to pharmacy benefit management? If so, list each business unit or entity, and briefly describe the nature of the business conducted. | ||
| 30. | General Information | Does your organization own or operate any business units or entities that provide marketing guidance or any other strategic consulting services to pharmaceutical companies? If so, what is the total annual revenue associated with that business unit for the most recent full fiscal year? Enter number only. | ||
| 31. | General Information | Confirm that your organization will provide the following transitional support after termination of the proposed arrangement, within a mutually agreeable reasonable timeframe, and at no extra charge to CLIENT. | ||
| x | a | 31. (a) | General Information | Delivery of Open Mail Order Refill data file to new vendor (initial and clean-up) |
| x | b | 31. (b) | General Information | Delivery of Open Prior Authorization data file to new vendor (initial and clean-up) |
| x | c | 31. (c) | General Information | Delivery of Accumulator Tracking data file to new vendor (initial and clean-up) |
| x | d | 31. (d) | General Information | Delivery of detailed claims data file for prior 12 months of data to new vendor (in a standard format, inclusive of all financial fields) |
| x | e | 31. (e) | General Information | Facilitation and support for client audits, in accordance with their contractual audit rights. |
| 32. | General Information | Which categories of revenue does your organization intend to rely on for profitability under your proposed arrangement for CLIENT? | ||
| x | a | 32. (a) | General Information | Base administrative fees |
| x | b | 32. (b) | General Information | Clinical program fees or other ancillary fees |
| x | c | 32. (c) | General Information | Formulary and market share rebates |
| x | d | 32. (d) | General Information | Rebate administration fees |
| x | e | 32. (e) | General Information | Clinical program funding from pharmaceutical companies |
| x | f | 32. (f) | General Information | Inflation protection revenue |
| x | g | 32. (g) | General Information | Revenue from the sale of client data or research |
| x | h | 32. (h) | General Information | Margin or mark-up on retail claims |
| x | i | 32. (i) | General Information | Retail network participation fees from retail pharmacies |
| x | j | 32. (j) | General Information | Margin or mark-up on mail order (non-specialty) claims |
| x | k | 32. (k) | General Information | Margin or mark-up on mail order specialty claims |
| 33. | General Information | Confirm that your organization will maintain total compliance with all HIPAA requirements including, but not limited to safeguards of data integrity, confidentiality, and availability? | ||
| 34. | General Information | What is the number of individuals currently employed in full-time capacity for each of the following roles within your organization? | ||
| x | a | 34. (a) | General Information | Account Executives (individuals serving as the primary accountable strategic representative for CLIENT) |
| x | b | 34. (b) | General Information | Account Managers (individuals responsible for day-to-day management of CLIENT's pharmacy arrangement) |
| x | c | 34. (c) | General Information | Clinical Consultants or Clinical Advisors (pharmacists responsible for advising CLIENT and providing strategic recommendations regarding clinical plan management) |
| x | d | 34. (d) | General Information | Customer Service Representatives (individuals responsible for answering calls from members and responding to member inquiries). |
| x | e | 34. (e) | General Information | Compliance Consultants (individuals serving in a CLIENT-facing role that provides expertise and assistance on Medicare Part D guidance for CLIENTs. |
| x | f | 34. (f) | General Information | Implementation Managers (individuals responsible for project management of CLIENT implementations). |
| 35. | General Information | In the event that CLIENT terminates their agreement with you, confirm that you will provide the following: | ||
| x | a | 35. (a) | General Information | Transfer of up to 24 months of historical claims data to new vendor in standard format at no charge |
x b 35. (b) General Information Creation and delivery of data file to new vendor for the transfer of open mail order claims at no charge x c 35. (c) General Information Creation and delivery of data file to new vendor for the transfer of open prior authorizations and/or other clinical approvals at no charge x d 35. (d) General Information Run-out processing of paper claims incurred during contract term
| 36. | Account Management | Confirm that CLIENT will have the ability to interview and approve any proposed new account team members. | ||
| 37. | Account Management | Confirm that your agreement that CLIENT will have the ability to request a change in any of the assigned teams based on unsatisfactory performance levels as determined by CLIENT. | ||
| 38. | Account Management | Confirm that your account team will conduct formal quarterly conference calls to review outstanding issues and provide operational updates. | ||
| 39. | Account Management | Confirm that you can provide CLIENT with timely acknowledgement of issues communicated to your organization within at least 1 business day of notification by CLIENT. | ||
| 40. | Account Management | Confirm that your Account Team will meet with CLIENT in person on at least a quarterly basis to review plan performance (financial and clinical). This meeting schedule may be modified by CLIENT. | ||
| 41. | Account Management | Confirm that reports and agenda will be provided to CLIENT and consultant at least 5 business days prior to the quarterly in-person meeting | ||
| 42. | Account Management | Confirm that your organization will conduct a technical review of CLIENT's Summary Plan Descriptions, to ensure accuracy and completeness. | ||
| 43. | Account Management | Confirm that your organization will provide recommended Summary Plan Description language for any standard programs or services that are implemented during the contract term. | ||
| 44. | Account Management | Confirm that the Account Team will ensure CLIENT is notified and updated on potential and recently passed State and Federal regulations and/or administrative rules that affects the practice of pharmacy and/or directly or indirectly affects prescription drugs regardless of benefit. | ||
| 45. | Account Management | Confirm the Account Team will support and/or collaborate with CLIENT on responding to State and Federal draft regulations, administrative rules, and/or guidance that affects the practice of pharmacy and/or directly or indirectly affects prescription drugs regardless of benefit. | ||
| 46. | Account Management | Describe turnaround time (TAT), in days for issue resolution after discovery of the error, for the following: | ||
| x | a | 46. (a) | Account Management | Coding errors in your claims processing system description of standard errors |
| x | b | 46. (b) | Account Management | Errors that require system enhancements |
| x | c | 46. (c) | Account Management | Errors that are a compliance risk and any expedited process for these. |
| x | d | 46. (d) | Account Management | Member reimbursements that may be due to these errors. (Includes the TAT from discovery of error to when payment is calculated and reimbursements are sent to members). |
| x | e | 46. (e) | Account Management | Incorrect coverage determination indicating approval of a medication that should have been denied and resulting from incorrect application of coverage criteria by PBM Prior Authorization department. |
| 47. | Account Management | Describe your Corrective Action Plan (CAP) for the following scenario. Include steps in issuing communication to member, prescriber, and Plan and in this scenario, entity that would be financially responsible: |
An incorrect coverage determination and letter was sent to member indicating approval of a Medicare Part D Covered Product that should have been denied. Further research indicates that the PA department reviewer administered criteria incorrectly.
| 48. | Account Management | Confirm that your organization will agree to provide on-site support for annual open enrollment fairs at no charge. | |||
| 49. | Account Management | Will the account team notify CLIENT of the following events or issues? | |||
| x | a | 49. (a) | Account Management | Drug recalls | |
| x | b | 49. (b) | Account Management | Significant new drug introductions | |
| x | c | 49. (c) | Account Management | Upcoming patent expirations for highly-utilized drugs | |
| 50. | Account Management | Confirm that your organization will provide data, reporting, and relevant plan information requested by CLIENT to support CLIENT's involvement in any class-action lawsuits at no charge to CLIENT, both during the contract term and after termination. | |||
| 51. | Account Management | Does your organization currently administer rebates at the point-of-sale ("POS Rebates") for any clients? If so, for approximately how many clients? Enter number only. | |||
| 52. | Account Management | Does your organization offer a self-service reporting tool allowing CLIENT to view plan performance reports? If so, which of the following reports or features are available through this tool: | |||
| x | a | 52. (a) | Account Management | List of top drugs by cost | |
| x | b | 52. (b) | Account Management | List of top drugs by utilization | |
| x | c | 52. (c) | Account Management | List of top disease states or drug class | |
| x | d | 52. (d) | Account Management | Adherence statistics by disease states or drug class | |
| x | e | 52. (e) | Account Management | List of drugs with high price inflation rates | |
| x | f | 52. (f) | Account Management | Benchmark of key statistics by Book of Business segment | |
| x | g | 52. (g) | Account Management | Benchmark of key statistics by custom (client-designated) benchmark group | |
| x | h | 52. (h) | Account Management | Savings calculations for clinical programs | |
| x | i | 52. (i) | Account Management | Prior authorization (PA) approval/denial rates, by drug or PA edit | |
| x | j | 52. (j) | Account Management | Financial statistics net of (including) rebate impact | |
| x | k | 52. (k) | Account Management | Pipeline projections | |
| x | l | 52. (l) | Account Management | Client-designed reports and/or queries | |
| x | m | 52. (m) | Account Management | Scheduled periodic reports | |
| x | n | 52. (n) | Account Management | Total claims costs with detail (Quarterly and Annually) | |
| x | o | 52. (o) | Account Management | Rebates ( in aggregate and by drug class) | |
| 53. | Account Management | Can your PBM support aggregated reporting of both medical and pharmacy data related to the Out of Pocket Maximum? Confirm there is no charge. | |||
| 54. | Account Management | Confirm agreement to provide support and collaborate with clients' actuarial designee(s) on quarterly trend, pipeline and forecasting projections. | |||
| 55. | Account Management | Is this tool customizable for CLIENT to build their own reports and queries? | |||
| 56. | Account Management | Provide an example of reports in your standard quarterly and annual reporting package. Submit as Exhibit - <Vendor Name> - Standard Reporting Package. | Include as Exhibit | ||
| 57. | Account Management | Briefly describe any forecasting reporting tools available currently. Indicate if these tools are accessible to CLIENT (at no additional charge) or only to the Account Team. | |||
| 58. | Account Management | Briefly describe your quality control efforts to ensure all reporting, especially compliance reporting, is accurate on an ongoing basis. | |||
| 59. | Account Management | Are there any limitations on the number of employees of CLIENT that can have access to this reporting tool? | |||
| 60. | Account Management | Confirm that you will provide standard financial reports (both electronic and if requested, hard copy) within 30 days from the close of the reporting period unless otherwise specified. | |||
| 61. | Account Management | Confirm that CLIENT will not need to request these reports and they will be generated and delivered automatically by the Account Team. | |||
| 62. | Account Management | Confirm that you agree to provide comprehensive and all inclusive quarterly Service and Performance Guarantee Tracking and Reporting to CLIENT. | |||
| 63. | Account Management | Confirm that you will train and support CLIENT's Underwriting designee(s) on case specific underwriting and determining group specific discounts, and/or guarantees. | |||
| 64. | Account Management | Confirm that your PBM will monitor fluctuations in drug prices and utilization on an on-going basis and promptly notify CLIENT of potential issue(s) that must be addressed, including solution(s) to address issue(s). | |||
| 65. | Account Management | Your organization will provide detailed pricing reconciliation reports to CLIENT within 90 days of the end of the relevant measurement period (i.e. calendar year guarantees will be reconciled and reported by March 31). The reports will demonstrate actual plan performance as compared to all relevant contractual pricing guarantees, and will include sufficient information about the methodology of the reconciliation to allow CLIENT or a third party to independently validate the results. | |||
| 66. | Account Management | Which of the following reports are available as part of your standard reporting package that is delivered to CLIENT on a periodic (i.e. quarterly) basis? | |||
| x | a | 66. (a) | Account Management | List of top drugs by cost | |
| x | b | 66. (b) | Account Management | List of top drugs by utilization | |
| x | c | 66. (c) | Account Management | List of top disease states or drug class | |
| x | d | 66. (d) | Account Management | Adherence statistics by disease states or drug class | |
| x | e | 66. (e) | Account Management | List of drugs with high price inflation rates | |
| x | f | 66. (f) | Account Management | Benchmark of key statistics by Book of Business segment | |
| x | g | 66. (g) | Account Management | Benchmark of key statistics by custom (client-designated) benchmark group | |
| x | h | 66. (h) | Account Management | Rebates ( in aggregate and by drug class) | |
| x | i | 66. (i) | Account Management | Savings calculations for clinical programs | |
| x | j | 66. (j) | Account Management | Prior authorization (PA) approval/denial rates, by drug or PA edit | |
| x | k | 66. (k) | Account Management | Financial statistics net of (including) rebate impact | |
| x | l | 66. (l) | Account Management | Pipeline projections | |
| x | m | 66. (m) | Account Management | Client-designed reports and/or queries | |
| x | n | 66. (n) | Account Management | Scheduled periodic reports | |
| 67. | Account Management | Your organization will be required to provide detailed pricing reconciliation reporting that will clearly demonstrate actual plan performance as compared to all relevant contractual pricing guarantees (discounts, dispensing fees, and rebates). Confirm your reports will include the following: | |||
| x | a | 67. (a) | Account Management | Your report includes sufficient information about the methodology of the reconciliation to allow CLIENT or a third party to independently validate the results. | |
| 68. | Account Management | Confirm that CLIENT will be assigned an Executive Sponsor and the Executive Sponsor will attend no less than one face to face meeting annually. Executive Sponsor will be required to attend additional meetings at the reasonable request of CLIENT. | |||
| 69. | Account Management | Provide the following information about the proposed Executive Sponsor for CLIENT: | |||
| x | a | 69. (a) | Account Management | Name | |
| x | b | 69. (b) | Account Management | Location (City, State) | |
| x | c | 69. (c) | Account Management | Number of years employed by your organization | |
| x | d | 69. (d) | Account Management | Number of years industry experience | |
| x | e | 69. (e) | Account Management | Number of accounts that this individual currently services | |
| x | f | 69. (f) | Account Management | Estimated percentage of time that this individual will dedicate to CLIENT | |
| 70. | Account Management | Indicate which of any of the core Account Team members will be dedicated (exclusive) to CLIENT. | |||
| 71. | Account Management | Confirm that if there is a change in Account Team(s) members, you will allow CLIENT to be part of the interview process of potential candidates. | |||
| 72. | Account Management | Confirm that the named Account Team members will remain in place for no less than 12 months from the first day of the effective date of this contract unless a team member is voluntarily or involuntarily terminated from your company. | |||
| 73. | Account Management | Confirm that a support person will be always available to work with CLIENT to resolve any issues around member eligibility and accumulator data. | |||
| 74. | Account Management | Confirm that your Account Team will maintain an account issue tracking log that is updated weekly and provided to CLIENT which includes but is not limited to, CLIENT issues, notification date of issue, documented progress toward resolution, individuals responsible for facilitating closure, and target date for resolution and documentation when completed. | |||
| 75. | Account Management | Provide the following information about the proposed Account Executive (the primary accountable strategic representative for CLIENT): | |||
| x | a | 75. (a) | Account Management | Name | |
| x | b | 75. (b) | Account Management | Location (City, State) | |
| x | c | 75. (c) | Account Management | Number of years employed by your organization | |
| x | d | 75. (d) | Account Management | Number of years industry experience | |
| x | e | 75. (e) | Account Management | Number of accounts that this individual currently services | |
| x | f | 75. (f) | Account Management | Estimated percentage of time that this individual will dedicate to CLIENT | |
| 76. | Account Management | Provide the following information about the proposed Account Manager (responsible for day-to-day management of the pharmacy arrangement) for CLIENT: | |||
| x | a | 76. (a) | Account Management | Name | |
| x | b | 76. (b) | Account Management | Location (City, State) | |
| x | c | 76. (c) | Account Management | Number of years employed by your organization | |
| x | d | 76. (d) | Account Management | Number of years industry experience | |
| x | e | 76. (e) | Account Management | Number of accounts that this individual currently services | |
| x | f | 76. (f) | Account Management | Estimated percentage of time that this individual will dedicate to CLIENT | |
| 77. | Account Management | Provide the following information about the proposed Clinical Consultant or Clinical Advisor (pharmacist responsible for providing strategic recommendations regarding clinical plan management) for CLIENT: | |||
| x | a | 77. (a) | Account Management | Name | |
| x | b | 77. (b) | Account Management | Location (City, State) | |
| x | c | 77. (c) | Account Management | Number of years employed by your organization | |
| x | d | 77. (d) | Account Management | Number of years industry experience | |
| x | e | 77. (e) | Account Management | Number of accounts that this individual currently services | |
| x | f | 77. (f) | Account Management | Estimated percentage of time that this individual will dedicate to CLIENT | |
| 78. | Account Management | Confirm you have the ability to receive and process eligibility files in CLIENT's standard or preferred output format at no charge to CLIENT. | |||
| 79. | Account Management | Confirm your PBM can accept eligibility and enrollment files from multiple vendors at no additional cost. | |||
| 80. | Account Management | Will CLIENT have the ability to manually update member and group eligibility and enrollment in your system, if CLIENT chooses to do so? | |||
| 81. | Account Management | What is the turnaround time (# of calendar days) for your PBM to complete member and group eligibility updates in your system after receipt of clean eligibility and enrollment information from CLIENT? |
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