Attachment F - Mandatory Requirements - PBM RFP 2025.xlsx
XLSX spreadsheet 19 KB Posted
- Attached to
- Pharmacy Benefits Manager (PBM)
- Solicitation number
- RFP-758-2500000221-4
- Issued by
- Elliott County, Kentucky
About this file
The document is a Mandatory Requirements attachment for a Pharmacy Benefit Manager (PBM) Request for Proposal (RFP) for the Kentucky Employees' Health Plan (KEHP), a state-level health benefits program. The RFP seeks a PBM vendor to provide comprehensive pharmacy benefit management services with a proposed contract start date of January 1, 2026, and requires vendors to comply with numerous state and federal healthcare regulations, including specific Kentucky Revised Statutes (KRS) related to health plan coverage.
The financial requirements mandate a transparent, pass-through pricing model with 100% rebate pass-through, no additional shipping fees, and an annual market check. Vendors must propose a three-year PBM solution using NADAC (National Average Drug Acquisition Cost) Methodology, provide a dedicated US-based customer service team, and demonstrate significant administrative experience by having either 450,000 covered lives nationwide with at least one client of 100,000 lives, or 1,000,000 covered lives with a client of 50,000 lives. Additional requirements include real-time claims monitoring, weekly data feeds, weekly plan management calls, and quarterly performance review meetings to ensure comprehensive service and ongoing plan optimization.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment M - Census Data - KEHP Formulary Disruption Final.xlsx | XLSX spreadsheet | |
| Attachment O - Census Data - KEHP Rx Plan Designs 2024.xlsx | XLSX spreadsheet | |
| Attachment N - Census Data - KEHP Network Disruption Final.xlsx | XLSX spreadsheet | |
| Attachment L - KEHP Pharmacy Claims Invoicing Document - PBM RFP 2025.xlsx | XLSX spreadsheet | |
| Final_RFP_758_2500000221_4_SO_FORM.PDF | ||
| Attachment I - KEHP Data Integration Chart - PBM RFP 2025.xlsx | XLSX spreadsheet | |
| Attahment K - BAA.pdf | ||
| Attachment H - Technical Questionnaire - PBM RFP 2025.xlsx | XLSX spreadsheet | |
| Attachment C - Prescriptions Filled from Nov 2023 through Oct 2024.pdf | ||
| Final_RFP_758_2500000221_2_SO_FORM.PDF | ||
| Attachment P - Census Data - KEHP Rx Plan Designs 2025.xlsx | XLSX spreadsheet | |
| Final_RFP_758_2500000221_1_SO_FORM.PDF | ||
| Attachment B - Cost Form - PBM RFP 2025.xlsx | XLSX spreadsheet | |
| Attachment J -DEI Billing Procedure Document.pdf | ||
| Final_RFP_758_2500000221_3_SO_FORM.PDF |
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Mandatory Requirments
| Mandatory Requirements | Format Type | Response | Explantion | |
| 1. | Vendor shall provide the required certification and attestation documents i.e., financial statements, certificates, affidavits as requested per the Proposal submission checklist within Attachment A. The vendor shall provide all required KEHP data for the annual audit, to ensure compliance with KRS 18A.2254(3)(e). | 1: Agree, |
2: Disagree (explain): [ Text ]
2. Any carrier bidding to offer health care coverage to employees shall agree to provide enrollment, claims, and utilization data to the Commonwealth/DEI in a format specified by the Personnel Cabinet with the understanding that the data shall be owned by the Commonwealth/DEI; to provide data in an electronic form and within a time frame specified by the Personnel Cabinet; and to be subject to penalties for noncompliance with data reporting requirements as specified by the Personnel Cabinet. The Personnel Cabinet shall take strict precautions to protect the confidentiality of each individual employee; however, confidentiality assertions shall not relieve a carrier from the requirement of providing stipulated data to the Commonwealth. See KRS 18A.225(2)(d). 1: Agree, 2: Disagree (explain): [ Text ]
3. Vendor shall comply with all federal and all state law requirements. The vendor shall provide all data with plan year identifiers, to ensure compliance with KRS 18A.2254(3)(a), (b), and (d). 1: Agree, 2: Disagree (explain): [ Text ]
4. Vendor shall comply with all federal and state law requirements. The respondent will comply with all mandatory requirements including but not limited to the list below for the Kentucky Employees' Health Plan (KEHP). 1: Agree, 2: Disagree (explain): [ Text ]
a. Hearing Aid coverage, KRS 18A.225(14) 1: Agree, 2: Disagree (explain): [ Text ]
b. Coverage for treatment of autism-spectrum disorders. KRS 18A.225(15) 1: Agree, 2: Disagree (explain): [ Text ]
c. Coverage for obtaining amino acid-based elemental formula. KRS 18A.225(16) 1: Agree, 2: Disagree (explain): [ Text ]
d. Provide the same payment of coverage to optometrists as allowed for those services rendered by physicians or osteopaths. KRS 18A.225(21). 1: Agree, 2: Disagree (explain): [ Text ]
e. Applicable coverage and care requirements listed in KRS 18A.225(22). 1: Agree, 2: Disagree (explain): [ Text ]
f. No individualized premiums. See KRS 18A.2254(1)(f). 1: Agree, 2: Disagree (explain): [ Text ]
g. Various PBM prohibitions. See KRS 304.17-595(2)(b). 1: Agree, 2: Disagree (explain): [ Text ]
5. Compliance with real-time claims monitoring, to the extent required by Commonwealth/DEI, including but not limited to providing a feed of adjudicated claims on at least a weekly basis. See KRS 18A.2258. 1: Agree, 2: Disagree (explain): [ Text ]
6. Vendor shall allow KEHP unlimited data file feeds to and from third party vendors at no additional charge. 1: Agree, 2: Disagree (explain): [ Text ]
7. Vendor hereby confirms that the Medical Network and Claims Administrator has been operating as an administrator for a minimum of five (5) years. 1: Agree, 2: Disagree (explain): [ Text ]
8. Vendor hereby confirms that the respondent has either (1) collectively 450,000 or more covered lives nationwide currently receiving Network and Claims administration; and has at least one client with 100,000 or more lives or (2) collectively 1,000,000 or more covered lives nationwide currently recieving Network and Claims administration and has at least one client with 50,000 or more lives. 1: Agree, 2: Disagree (explain): [ Text ]
9. Vendor shall provide KEHP with a dedicated account team to address service-related issues and client specific medical benefit needs if the number of enrolled employees is >100,000. 1: Agree, 2: Disagree (explain): [ Text ]
10. Vendor shall provide KEHP with a dedicated, 100% US-based customer service team to address service-related issues and client specific medical benefit needs. This requirement applies to any phone, chat, customer service centers, mail handling facilities, data storage or debt collection services, or any other customer service operations. 1: Agree, 2: Disagree (explain): [ Text ]
11. The Vendor shall cooperate with the Commonwealth/DEI in analyzing the impact of proposed legislation on the operation of the Contract. Unless otherwise directed by the Commonwealth/DEI, the Vendor shall respond In Writing with a summary of Plan impact and cost breakdown analysis to all inquiries from the Commonwealth regarding responses to proposed legislation within forty-eight (48) hours of the Commonwealth/DEI’s request, whenever possible. The Vendor shall defer to the Commonwealth/DEI’s interpretation of the applicability of proposed legislation to the Plans. 1: Agree, 2: Disagree (explain): [ Text ]
12. The Contractor shall have a dedicated healthcare concierge customer service and advocacy staff to support Members with resources and services, either through Vendor employes and Vendor-owned systems and products, or through pre-existing strategic partnerships. 1: Agree, 2: Disagree (explain): [ Text ]
13. Vendor shall allow KEHP to change data fields/layout/files to meet state and federal requirements, new vendor program implementations and data warehouse needs at no additional charge. These reporting requirements include, but are not limited to: 1: Agree, 2: Disagree (explain): [ Text ]
a. Health Plan Transparency in Coverage Final Rule published at 85 Fed. Reg. 72158 1: Agree, 2: Disagree (explain): [ Text ]
b. No Surprises Act as enacted pursuant to Division BB, Title I, Sections 101-118 of the Consolidated Appropriations Act of 2021 1: Agree, 2: Disagree (explain): [ Text ]
c. Removing Gag Clauses on Price and Quality Information as required pursuant to Division BB, Title II, Section 201 of the Consolidated Appropriations Act of 2021 1: Agree, 2: Disagree (explain): [ Text ]
d. Strengthening Parity in Mental Health and Substance Use Disorder Benefits as required pursuant to Division BB, Title II, Section 203 of the Consolidated Appropriations Act of 2021 1: Agree, 2: Disagree (explain): [ Text ]
e. Non-Quantitative Treatment Limitations and Mental Health Parity Act reporting, including such reporting to the Kentucky Department of Insurance, as required. 1: Agree, 2: Disagree (explain): [ Text ]
22. Vendor agrees to send and receive deductible and out-of-pocket accumulator information with the KEHP’s Medical administrator on a daily basis. 1: Agree, 2: Disagree (explain): [ Text ]
23. Vendor agrees to provide customization and flexibility to meet the KEHP's requirements including, but not limited to: customized ID cards, data integration with multiple third-party vendors, customized reporting, ad hoc reporting and customization of participant forms/communication materials. 1: Agree, 2: Disagree (explain): [ Text ]
24. Vendor agrees to participate in weekly plan management / open items calls to review plan progress, member inquiries, customer service issues, escalated claims reviews, etc. Each call will include an open items log to be managed by bidder’s account management team. Open items log will include open issue date, status, targeted close date, and a resolution plan. 1: Agree, 2: Disagree (explain): [ Text ]
25. Vendor agrees to participate in quarterly meetings, semi-annual performance review meetings and annual plan performance review meetings to review claims utilization, clinical program effectiveness, contracting updates, recommendations to improve plan performance and/or member experience, and performance guarantee status. 1: Agree, 2: Disagree (explain): [ Text ]
| 26. | Financial requirements include, but not limited to: | ||
| a. | Bidder must agree to provide a 3-year PBM proposal using NADAC Methodology effective 01/01/2026. | 1: Agree, |
2: Disagree (explain): [ Text ]
b. Financial offer MUST COMPLY with all Bidding Requirements and requirements in the Financial Questionnaire. 1: Agree, 2: Disagree (explain): [ Text ]
c. Financial offer must include a transparent and pass-through bids for discounts, dispensing fees and rebates. 1: Agree, 2: Disagree (explain): [ Text ]
d. Financial offer must include rebates 100% pass-through including 100% of amounts achieved above any minimum rebate guarantees. 1: Agree, 2: Disagree (explain): [ Text ]
e. Financial offer will include an annual market check. 1: Agree, 2: Disagree (explain): [ Text ]
f. Bidder must account for rebate credits that are not biosimulars 1: Agree, 2: Disagree (explain): [ Text ]
g. Bidder agrees the financial offer proposed is based on no future rebate credit, biosimular exclusive arrangements, non-copay preferred positon, and Low WAC basis 1: Agree, 2: Disagree (explain): [ Text ]
h. Bidder agrees to no shipping and handling fees 1: Agree, 2: Disagree (explain): [ Text ]
i. The financial offer will be inclusive of all pricing terms and conditions, including all service and/or admin fees; these pricing terms and conditions will not change throughout the contract term unless a new program is implemented, at a client renewal or RFP official exercise and only with the client's agreement and approval of any change to the pricing terms and conditions. 1: Agree, 2: Disagree (explain): [ Text ]
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