Attachment H - Technical Questionnaire - PBM RFP 2025.xlsx

Questionnaire

To Vendor: Use Column F to provide a brief explanation. However if the length of the explanation is greater than 50 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.

If your answer is "Partial Agree/Disagree", please explain the specific aspect of the requirement you do not agree with and why. Note that exceptions may be cause for elimination from further consideration.

New Drug Additions Report For the avoidance of doubt, the terms, terminology, and statutory references addressed within Attachment A (Section 6.7 and Section 10) take precedence over language within the Questionnaire and supporting appendices.

a) mail-order drug option for maintenance drugs for state employees, with net cost limitation. See KRS 18A.225(13)(a), KRS 18A.2259.

b) Non-discrimination against any retail pharmacy located in KY. See KRS 18A.225(13)(b).

c) advance written notice of any formulary change to impacted members at least 15 days before implementation of any formulary change, and revised formulary documents to DEI at least 20 days before such change, so DEI may publish before such implementation. See KRS 18A.2254(1)(c).

d) Any formulary shall have a compliant exceptions policy. See KRS 18A.2254(1)(e), KRS 304.17A-535.

e) Compliance with real-time claims monitoring and coordination with claims monitoring auditor, to the extent required by DEI. See KRS 18A.2258.

2: Disagree, explain: [ Text ]

14. You will comply with all applicable rules, regulations, and legislation directly or indirectly related to the provision of PBM services at no additional cost to Client. 1: Agree, 2: Disagree, explain: [ Text ]

15. You will disclose and certify all sources of revenue on an annual basis. 1: Agree, 2: Disagree, explain: [ Text ]

16. You agree that amounts owed to Client during the course of the contract term, including but not limited to Manufacturer Payments, pricing and performance guarantee shortfalls, recoveries identified during Claims audits, will be paid by the appropriate due date. Any amounts unpaid ten (10) calendar days after the stated due date will bear interest at SOFR (or another prevailing benchmark rate) plus 1% per month or the highest interest rate allowed by law 1: Agree, 2: Disagree, explain: [ Text ]

17. Your organization can administer Client's current benefit designs and provisions. This includes and is not limited to your ability to administer integrated medical and Rx deductibles and out of pocket maximums on a real time basis for qualified HDHPs and other plan types at no cost to Client. If you cannot administer specific provisions for Client, please identify those in a separate attachment and specify. Additionally, Client will not be held financially responsible for any IT services fees tied to the build of new connections, maintenance or adjustment of already existing connections needed to administer real time data feeds. 1: Agree, 2: Disagree, explain: [ Text ]

18. Your proposed pricing is based on Client’s specific plan designs currently in effect. PBM further attests that the proposed pricing that is agreed to and made a part of the final contracts executed by Client and no alterations in plan designs are required of Client to achieve the pricing represented in its bid. 1: Agree, 2: Disagree, explain: [ Text ]

19. Impact of Clinical Programs on Lowest Net Ingredient Cost - PBM agrees that it will not implement any program that results in the conversion from a lower net cost drug to a higher ingredient net cost drug without the prior consent of Client. Further, PBM agrees that it will not implement any program that results in conversion of a lower member cost share drug to a member having to pay a higher cost share. 1: Agree, 2: Disagree, explain: [ Text ]

20. Confirm that you have completed the Retail Pharmacy Network Disruption Worksheet excel file with a tab for Client (provided as separate attachment). The completed file should be submitted as an attachment with your RFP response. 1: Agree, 2: Disagree, explain: [ Text ]

21. Confirm that you have completed the Formulary Disruption Worksheet excel file with a tab for Client (provided as separate attachment). The completed file should be submitted as an attachment with your RFP response. 1: Agree, 2: Disagree, explain: [ Text ]

2: Disagree, explain: [ Text ]

23. Your completed proposal contains the form (included in the "Officer Statement" worksheet), signed by a company officer, attesting to compliance with RFP specifications and the accuracy of all responses.

2: Disagree, explain: [ Text ]

Definitions

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

2: Disagree (explain): [ Text ]

2. “Adjusted Claims” means a 30-day supply Claim equivalent, that shall be calculated as follows: Adjusted Claim = [Claim Days Supply] / [30 days]. For avoidance of doubt, a Claim with a 90-day supply would constitute three (3) Adjusted Rx. A Claim with a 10 (ten) day supply would constitute 1/3 (one-third) of an Rx. 1: Agree, 2: Disagree (explain): [ Text ]

3. "Administrative Fee(s)" means the fee paid to PBM for agreed upon PBM services. 1: Agree, 2: Disagree (explain): [ Text ]

4. “Average Wholesale Price” or “AWP” means the average wholesale price per unit for a product's NDC-11 on the date the claim is adjudicated as set forth from the most current pricing information from Medi-Span. 1: Agree, 2: Disagree (explain): [ Text ]

2: Disagree (explain): [ Text ]

6. “Biosimilar Product” or “Biosimilar” means a biological product that is highly similar to a US-licensed reference biological product notwithstanding minor differences in clinically inactive components, and for which there are no clinically meaningful differences between the biological product and the reference product in terms of the safety, purity, and potency of the product as defined in the Biologics Price Competition and Innovation Act of 2009 at 42 U.S.C. §262(i)(2) and approved under Section 351(k) of the Public Health Services Act and as identified in the Purple Book. 1: Agree, 2: Disagree (explain): [ Text ]

7. "Brand Drug" or "Brand Product" means an FDA approved drug, or a drug that is designated by FDA a DESI (Drug Efficacy Study Implementation) drug, or product, which is manufactured and distributed by an innovator drug company, or its licensee , set forth in Medi-Span’s National Drug Data File (MS) as a brand drug identified by all of the products meeting at least one of the following criteria:

1. Brand Name code of “T” and Multisource Code “M”

2. Brand Name code of “B” or “T” and Multisource Code of “N”

3. Brand Name code of “B” or “T” and Multisource Code “O” and a DAW code of 0, 1, 2, 7, 8, or 9

For the avoidance of doubt, Brand Drugs shall also include, brand name vaccines, supplies, medical devices, kits, diabetic supplies, OTCs and test strips. 1: Agree, 2: Disagree (explain): [ Text ]

8. “Claim(s)” means any electronic or paper request for payment or reimbursement processed through PBM’s on-line claims adjudication system or otherwise transmitted or processed in accordance with the terms of an agreement in connection with Commonwealth/DEI 's Plan, including claims in which the Member pays the full cost and Commonwealth/DEI has no cost liability, but does not include requests for payment or reimbursement that (i) rejected due to system edits designed to enforce Commonwealth/DEI's pharmacy benefit programs or were reversed or cancelled from the claim payment system. 1: Agree, 2: Disagree (explain): [ Text ]

9. “ Client” means Commonwealth/DEI or Kentucky Employees' Health Plan (KEHP). 1: Agree, 2: Disagree (explain): [ Text ]

10. “Client Pharmacy” means a Retail Pharmacy that has contracted with, and is identified by, Commonwealth/DEI to dispense drugs to Members at reimbursement rates agreed-upon between the two parties. 1: Agree, 2: Disagree (explain): [ Text ]

11. “Compound Drug” shall mean a mixture of two (2) or more ingredients when at least one of the ingredients in the preparation is an FDA approved federal legend drug, and the mixture of which is not otherwise generally available in an equivalent commercial form or strength in response to a physician’s prescription to create a medication tailored to the specialized medically required need for an individual patient. A Compound Drug is identified by the compound indicator on the Claim feed. 1: Agree, 2: Disagree (explain): [ Text ]

12. "Continuity of Therapy Utilization” refers to the continued coverage of a medication, that is not on PBM's formulary, by a member who was receiving the drug on, or before the effective date of the agreement between the PBM and the Commonwealth/DEI. 1: Agree, 2: Disagree (explain): [ Text ]

13. "Coordination of Benefits" or COB Claim(s)" means a Claim where more than one health insurance program, policy, or other form of coverage, including governmental or non-governmental coverage, and Commonwealth/DEI acts as the secondary or tertiary payor for the Claim. 1: Agree, 2: Disagree (explain): [ Text ]

14. “Covered Drug" or "Covered Product” means a drug, device or supplies that is covered under the Formulary adopted by the Commonwealth/DEI and requires a prescription for dispensing and/or coverage as a plan benefit. 1: Agree, 2: Disagree (explain): [ Text ]

15. "Daily Cost Sharing Rate" means the one month co-pay divided by the number of days in a month's supply. For example, if your co-pay for a one-month supply of a drug is $30, and a one-month's supply in your plan is 30 days, then the daily cost-sharing rate is $1 per day. 1: Agree, 2: Disagree (explain): [ Text ]

16. "Data Fees" means fees received by PBM or PBM Affiliates for the sale of aggregate blinded data to a limited group of third parties including nationally recognized data integration firms. 1: Agree, 2: Disagree (explain): [ Text ]

17. "Days' Supply" means the number of days the Brand Drug, Generic Drug or Specialty Drug is to be taken as prescribed and submitted to PBM by the dispensing Pharmacy. 1: Agree, 2: Disagree (explain): [ Text ]

18. "Dispensing Fee(s)" means the fee paid to the dispensing pharmacy for the professional service of filling a claim and is equal to the Total Claim Cost less the Ingredient Cost and less the applicable sales tax. U&C Claims will always have a zero dollar Dispensing Fee. 1: Agree, 2: Disagree (explain): [ Text ]

20. "Fill Quantity" means the number of units (e.g. tablets, capsules, mL) of a product that is dispensed for a Claim as submitted to PBM by the dispensing Pharmacy. 1: Agree, 2: Disagree (explain): [ Text ]

21. “Formulary” means the list of FDA-approved prescription drugs and supplies developed by PBM’s Pharmacy and Therapeutics Committee (“P&T Committee”). The Formulary consists of (i) a ranking of Covered Products into preferred and non-preferred tiers, (ii) a listing of Non-Covered Products, and (iii) associated utilization review programs pursuant to PBM’s standard clinical criteria, which may include, but not limited to, prior authorizations, step therapy and/or quantity limits for one or more Covered Products. 1: Agree, 2: Disagree (explain): [ Text ]

22. "Formulary Rebate(s)" or "Access Rebate(s)" means a rebate collected by PBM or PBM Affiliates from pharmaceutical companies for products where the implemented formulary encourages Member use over other products and is attributable to Commonwealth/DEI's specific utilization. 1: Agree, 2: Disagree (explain): [ Text ]

23. "Generic Drug" or "Generic Product" means an FDA approved drug, or a drug that is designated by FDA a DESI (Drug Efficacy Study Implementation) drug, or product, that is therapeutically equivalent to other pharmaceutically equivalent products, as set forth in Medi-Span’s National Drug Data File (MS) as a generic drug identified by all products meeting at least one of the following criteria:

1. Brand Name code of “G” for all Multisource Codes (M, N, O, and Y)

2. Multisource Code of “Y”

3. Multisource Code of “M” with a Brand Drug Code of “B” (Authorized Generic)

4. “O” with a DAW code of 3, 4, or 6

5. Multisource Codes (M, N, O, and Y) with a DAW code of 5 (House Generic).

For the avoidance of doubt, Generic Drugs shall also include, generic vaccines, supplies, medical devices, kits, diabetic supplies, OTCs and test strips. 1: Agree, 2: Disagree (explain): [ Text ]

24. “Group Purchasing Organization” or “GPO” is an entity that aggregates the purchasing power of a group of businesses to obtain discounts or rebates from pharmaceutical manufacturers. These services may include contracting with manufacturers for Manufacturer Payments or any similar service conducted on behalf of the PBM. Any entity who provides the same or similar services as the PBM on behalf of the PBM under this Agreement shall also be considered a GPO. For purposes of this Agreement, rebate aggregators or any similar/competing entity shall also be a GPO.

PBM represents and warrants that PBM’s agreements with a Group Purchasing Organization shall contain (and will continue to contain through the term of this Agreement) provisions or obligations that are substantially similar to any provision or obligation contained in this Agreement which directly or indirectly relates to any service under this Agreement that is or may be performed by a GPO as defined herein. A breach of this representation and warranty shall be considered a material breach of this Agreement. 1: Agree, 2: Disagree (explain): [ Text ]

25. “Guaranteed Minimum Manufacturer Payment” or “Rebate Guarantee” is the minimum Rebate per Brand Drug by dispensing channel. The performance will be calculated for the annual period using the following formula for each dispensing Channel independently, then summed: 'The calculation of the Annual Rebate Guarantee Amount will be [Rebate Guarantee] multiplied by [total Brand Drug count minus the exclusions as outlined in Rebate exclusions in the Rx-Pricing, Exclusions Tab]. 1: Agree, 2: Disagree (explain): [ Text ]

26. "Guaranteed Price" shall mean the resulting Ingredient Costs plus Dispensing Fees subject to the pricing guarantees (in Rx-Pricing, Discount & DF) and the pricing exclusions (in Rx-Pricing, Exclusions). 1: Agree, 2: Disagree (explain): [ Text ]

27. "Home Infusion Pharmacy" or "HIF" means a Retail Pharmacy-based, decentralized patient care organization with expertise in USP 797-compliant sterile drug compounding that provides care to patients with acute or chronic conditions generally pertaining to parenteral administration of drugs, biologics and nutritional formulae administered through catheters and/or needles in home and alternate sites. These Pharmacies are identified by a National Council for Prescription Drug Program’s (NCPDP’s) dispenser type code of 6. 1: Agree, 2: Disagree (explain): [ Text ]

28. "House Generics" means a Brand Drug submitted with a Dispense As Written (DAW) 5 code in place of the generic equivalent and where the pharmacy is reimbursed at a Generic Drug rate, including MAC, as applicable. For reconciliation of the Generic Drug discount guarantees, the AWP of House Generic drugs shall be the per unit AWP of the generic equivalent and not the AWP of the Brand Drug. House Generics will be identified using Medi-Span Multisource Code M, N, O, or Y and a Dispense as Written (DAW) code of 5. 1: Agree, 2: Disagree (explain): [ Text ]

29. "Incentive Rebate(s)" means a rebate collected by PBM or PBM Affiliates from pharmaceutical companies for products where restrictions on competitor products have been put in place and is attributable to Commonwealth/DEI's specific utilization. 1: Agree, 2: Disagree (explain): [ Text ]

30. "Indian Health Services, Tribal or Urban Indian Health" or "I/T/U" means a Retail Pharmacy operated by the Indian Health Service, an Indian tribe or tribal organization, or an urban Indian organization as defined in Section 4 of the Indian Health Care Improvement Act, 25 U.S.C. 1603. These Pharmacies are identified by a National Council for Prescription Drug Program’s (NCPDP’s) dispenser type code of 8. 1: Agree, 2: Disagree (explain): [ Text ]

31. “Inflation Protection Payments” means payments received by your firm (if any; and whether separately made or in the form of increased Rebates) or PBM Affiliates from a pharmaceutical manufacturer for the purpose of adjusting for year over year price inflation of the manufacturer’s price to your firm for prescriptions on which Rebates are paid; in accordance with and pursuant to applicable pharmaceutical manufacturer agreements. 1: Agree, 2: Disagree (explain): [ Text ]

32. "Ingredient Cost" means the discounted AWP cost of a Claim and is equal to the Total Claim Cost less the applicable Dispensing Fee and less the applicable sales tax. 1: Agree, 2: Disagree (explain): [ Text ]

33. "Limited Distribution Specialty Drugs" are those Specialty Drugs only available through select pharmacy providers as determined by the drug manufacturer. 1: Agree, 2: Disagree (explain): [ Text ]

34. "Long Term Care Pharmacy" or "LTC" means a Retail Pharmacy that dispenses medicinal preparations delivered to patients residing within an intermediate or skilled nursing facility, including intermediate care facilities for mentally disabled, hospice, assisted living facilities, group homes, and other forms of congregate living arrangements. These Pharmacies are identified by a National Council for Prescription Drug Program’s (NCPDP’s) dispenser type code of '04'. 1: Agree, 2: Disagree (explain): [ Text ]

35. “Mail Order Pharmacy” or "Mail Order" means an automated Pharmacy that processes prescriptions at one or more central locations and delivers them through the mail or other third-party delivery service to the locations of customers and does not have a physical customer-facing storefront. If such an automated pharmacy dispenses Specialty Drugs and non- Specialty Drugs, such Mail Order Pharmacy shall constitute a Mail Order Pharmacy solely with respect to the dispensing of non-Specialty Drugs and shall constitute a Specialty Pharmacy with respect to the dispensing of Specialty Drugs. These Pharmacies are identified by a National Council for Prescription Drug Program’s (NCPDP’s) dispenser type code of '05'. 1: Agree, 2: Disagree (explain): [ Text ]

36. "Manufacturer Administrative Fee(s)" means fees for services rendered to pharmaceutical manufacturers in relation to administrative duties in connection with aggregation, allocating, collecting, and invoicing for rebates. Manufacturer Administrative fees are considered inclusive of "rebate administrative fee(s)," "formulary administrative fees," "GPO fees" or any other fee paid to PBM, PBM Affiliates, or a GPO in relation to administrative duties in connection with the collection of Manufacturer Payments. 1: Agree, 2: Disagree (explain): [ Text ]

37. "Manufacturer Payments" includes Rebates, Manufacturer Administrative Fees, Inflation Protection Payments, and Data Fees, but excludes Other Pharmaceutical Manufacturer Revenue. 1: Agree, 2: Disagree (explain): [ Text ]

38. "Market Share Rebate(s)" or "Performance Rebate(s)" means a rebate collected by PBM or PBM Affiliates from pharmaceutical companies that is based on the utilization of a rebated product compared to the utilization of competitor products and is attributable to Commonwealth/DEI’s specific utilization. 1: Agree, 2: Disagree (explain): [ Text ]

39. "Maximum Allowable Cost" or "MAC" means the price that has been established by PBM for a Brand Drug or Generic Drug included on its MAC drug list, which may be amended from time to time by PBM. A copy of such MAC drug list shall be provided to Commonwealth/DEI prior to execution and upon Commonwealth/DEI’s reasonable request, and shall be updated by PBM in its sole discretion. The same MAC list will be used for a Retail Pharmacy, a Mail Order Pharmacy, and a Specialty Pharmacy (i.e. same number of drugs, same drugs). The Mail Order Pharmacy and Specialty Pharmacy MAC list price points for individual drugs/generic class numbers shall be equal to or less (i.e., more deeply discounted) than the Retail Pharmacy MAC price points for the same drugs/generic class numbers. 1: Agree, 2: Disagree (explain): [ Text ]

40. "MBI" means Medicare beneficiary Identifier 1: Agree, 2: Disagree (explain): [ Text ]

41. "Member(s)" means each individual (employee or dependent) who Commonwealth/DEI identifies in the eligibility file to be eligible for prescription drug benefits under its plan. 1: Agree, 2: Disagree (explain): [ Text ]

42. "Member Cost Share" means the amount which a Member is required to pay for a Claim in accordance with Commonwealth/DEI’s benefit design, which may be a deductible, a percentage of the Claim price, a fixed amount and/or other charge or penalty. 1: Agree, 2: Disagree (explain): [ Text ]

43. "Member-Submitted Claim(s)" or "Paper Claim(s)" means a Claim for which the Member paid the full amount of the Claim and was then submitted to PBM by a Member for reimbursement. These Claims are identified by the claim type code of ’3’ (pharmacy submitted paper claim) or ‘4’ (member submitted paper claim) 1: Agree, 2: Disagree (explain): [ Text ]

44. "Military Pharmacy" means a Retail Pharmacy whose primary function is to store, prepare and dispense pharmaceuticals and other associated items to uniformed services beneficiaries. These pharmacies may be associated with Department of Defense or U.S. Coast Guard clinic, Department of Defense hospital or freestanding. Usually associated with outpatient services. Associated with taxonomy code “332000000X”. These Pharmacies are identified by a National Council for Prescription Drug Program’s (NCPDP’s) dispenser type code of 17. 1: Agree, 2: Disagree (explain): [ Text ]

45. "MFN" means Most Favored Nation 1: Agree, 2: Disagree (explain): [ Text ]

46. "Network Pharmacy" means a Participating Pharmacy, Mail Order Pharmacy, Specialty Pharmacy, or other facility that is duly licensed to operate as a pharmacy at its location and to dispense prescription drugs to individuals, including members, and for third-part pharmacies, and have entered into a network pharmacy agreement. 1: Agree, 2: Disagree (explain): [ Text ]

47. “Non-Covered Products” or "Formulary Exclusions" shall mean drugs or other related products that are not Covered Products. All designations of products as Non-Covered Products shall be approved by PBM’s P&T Committee. 1: Agree, 2: Disagree (explain): [ Text ]

48. “Non-Preferred Rebates” mean payments collected by PBM or PBM Affiliates from Manufacturers for Claims that may be designated as non-preferred or non-covered via Formulary or utilization management criteria and are directly or indirectly attributable to Commonwealth/DEI’s specific utilization. 1: Agree, 2: Disagree (explain): [ Text ]

49. "Off-Invoice Wholesaler Remuneration" means various off-invoice reconciliation payments made by wholesalers to PBM that are not booked to an individual NDC and therefore not attributable to an individual Commonwealth/DEI. Examples of these payments include but are not limited to: true-ups, distribution fees, operational excellence fees, and price-protection credits. 1: Agree, 2: Disagree (explain): [ Text ]

50. "Other Pharmaceutical Manufacturer Revenue" means any revenue that PBM or PBM Affiliates receive from pharmaceutical manufacturers. This may include, but is not limited to: Off-Invoice Wholesaler Remuneration, Pharmacy Purchase Discounts (i.e. Mail Order Volume Discounts), Transmission Fees, and Specialty Service Fees. 1: Agree, 2: Disagree (explain): [ Text ]

51. "Out-of-Network Pharmacy" means a pharmacy that is not in the plan's preferred or standard network and will not cover prescription drugs. Members would be required to pay the full cost of prescriptions at an out-of-network pharmacy. 1: Agree, 2: Disagree (explain): [ Text ]

52. "Over-the-Counter Claim(s)" or "OTC Claim(s)" means a prescription Claim for products that do not necessarily require a prescription for a Member to purchase and that Commonwealth/DEI has chosen to or has been required to include as covered products under the prescription drug benefit. OTC Claims are defined as having an ‘O’ or 'P' indication in Medi-Span’s Rx-OTC Indicator Code. 1: Agree, 2: Disagree (explain): [ Text ]

53. “Part D Drugs” means the list of covered drugs that are included on a Medicare Part D (the prescription drug benefit) plan's formulary. 1: Agree, 2: Disagree (explain): [ Text ]

54. “Pharmacy and Therapeutics Committee" or "P&T Committee” shall mean an independent body of health care professionals and academicians recognized as national experts and leaders in their fields of specialty who periodically review new drugs introduced to the market, re-evaluate selected therapeutic drug classes and drugs in the pharmaceutical development pipeline, and evaluate any current, relevant drug safety issues. 1: Agree, 2: Disagree (explain): [ Text ]

55. “Participating Pharmacy” means a Retail Pharmacy, Mail Order Pharmacy, Specialty Pharmacy, non-traditional pharmacy (such as I/T/U, LTC, HIF, Military, TER or VA) or other Pharmacy that participates in the PBM’s network of Participating Pharmacies pursuant to an agreement between the Participating Pharmacy and PBM or between the Participating Pharmacy and Commonwealth/DEI for such Pharmacy’s dispensing of Covered Drugs to Members 1: Agree, 2: Disagree (explain): [ Text ]

56. "Pass Through Pricing”, "Pass-through", or "Transparent Pricing" means a pricing structure comprised of fixed guaranteed discounts at PBM's Mail Order Pharmacy and Specialty Pharmacy and a full pass through of PBM's contracted rates with Participating Pharmacies and pharmaceutical manufacturers. In this arrangement, PBM retains the difference between Mail Order and specialty acquisition costs and the amounts guaranteed to Commonwealth/DEI. PBM passes through (1) its contracted rates with Participating Pharmacies and (2) all Manufacturer Payments it receives from pharmaceutical manufacturers in excess of Commonwealth/DEI’s guaranteed Manufacturer Payments. The amount billed to Commonwealth/DEI and at Retail Pharmacies will be equal to the amount paid by PBM to the Retail Pharmacies. 1: Agree, 2: Disagree (explain): [ Text ]

57. "PBM Affiliates" of a party shall mean an entity:

(i) which is directly or indirectly, through one or more intermediaries, controlling such party;

(ii) which is under the same direct or indirect ownership or control as such party; or

(iii) which is directly or indirectly, through one or more intermediaries, owned or controlled by such party.

For purposes of this definition and the Agreement, “control” (including the terms controlling, controlled by or under common control with) means (a) the possession, direct or indirect, (b) the power to direct or cause the direction of the management or policies of an entity, or (c) the ability to direct an entity’s affairs or to control the composition of its board of directors or equivalent body, whether through (i) 50% of more of voting securities, (ii) partnership or membership interests, (iii) by contract or (iii) any other means.

Further, a Group Purchasing Organization shall also be considered a PBM Affiliate to the extent the GPO meets the above definition. 1: Agree, 2: Disagree (explain): [ Text ]

58. "Pharmacy" means a pharmacy that participates in the PBM network pursuant to an agreement between the pharmacy and PBM. 1: Agree, 2: Disagree (explain): [ Text ]

59. “Pharmacy Discount Cards” shall mean a prescription drug saving program that negotiate discounts at retail pharmacies by partnering with pharmacy benefit managers, in order to provide underinsured, terminated employees, and part-time employees with access to lower medication prices. Pharmacy Discount Card programs are marketed and distributed for free to patients who access the program by using the free card or mobile app provided by the savings program. 1: Agree, 2: Disagree (explain): [ Text ]

60. "Pharmacy Purchase Discount(s)" or "Volume Discount(s)" means discounts, paid at time of purchase, or retrospectively, received by PBM or its affiliates from pharmaceutical manufacturers, which are attributable to or based on products purchased by PBM affiliated dispensing pharmacies. 1: Agree, 2: Disagree (explain): [ Text ]

61. “Preferred Specialty Network” means a network arrangement where Commonwealth/DEI receives preferred pricing versus non-preferred Specialty Pharmacies. 1: Agree, 2: Disagree (explain): [ Text ]

62. “Pricing Source” means Medi-Span Prescription Guide including supplements. 1: Agree, 2: Disagree (explain): [ Text ]

63. “Prior Authorization” is a process used by insurance companies to determine if a prescribed product or service will be covered. This means if the product or service will be paid for in full or in part. This process can be used for certain medications, procedures, or services before they are given to the patient. 1: Agree, 2: Disagree (explain): [ Text ]

64. “Quantity Limits” means the highest amount of a prescription drug that can be given to a patient by a pharmacy in a period of time. 1: Agree, 2: Disagree (explain): [ Text ]

65. "Rebates" means the return of partial payments from a pharmaceutical manufacturer, pursuant to the terms of a rebate contract, negotiated directly or indirectly with a pharmaceutical company by PBM, PBM Affiliates, or a GPO, on behalf of all plan sponsors, and directly or indirectly attributable to the utilization of certain prescriptions by members. Rebates shall include Formulary Rebates (i.e. Access Rebates), Market Share Rebates (i.e. Performance Rebates), Incentive Rebates, Value-Based Rebates, Medical Drug Rebates (if carve-in with a Health Plan), and Non-Preferred Rebates. Rebates do not include the value of manufacturer coupons applied at the pharmacy or other patient assistance programs. 1: Agree, 2: Disagree (explain): [ Text ] "Rebate Credit" is a credit applied towards the achievement of the minimum Rebate guarantee. A Rebate Credit will apply if the minimum Rebate guarantee is materially impacted due to a Rebate Credit Qualifying Event. The following products will be eligible for Rebate Credit: (i) Any Biosimilar product processed, where WAC is at least 50% less than Humira and Humira is the reference Brand Drug; (ii) any insulin product that experiences a WAC or Rebate decrease through an AMP Cap-driven price reduction; or (iii) any other subsequent product impacted by any future AMP Cap-driven price reduction that results in a WAC or Rebate decrease, as demonstrated and communicated to Client, subject to mutual agreement which shall not be unreasonably withheld (collectively, a “Rebate Credit Qualifying Event”)

The “Rebate Credit” shall be determined as: (i) the difference between the expected Rebate revenue associated with the original rebated product (e.g., an originator Brand Drug or biologic) and the actual rebate amount received following the Rebate Credit Qualifying Event. In instances where the Wholesale Acquisition Cost (WAC) of any Biosimilar Claim processed and the WAC of the reference Brand Drug is less than the Rebate Credit applied, PBM will provide an explanation and modeling which shall be reviewed by the Client. Notwithstanding anything to the contrary, nothing herein is intended to amend or otherwise deviate from either parties’ rights listed in the Agreement. 1: Agree, 2: Disagree (explain): [ Text ]

66. “Retail Pharmacy” or "Retail" means any type of Pharmacy other than a Mail Order Pharmacy or Specialty Pharmacy, and includes any independent pharmacies, supermarket pharmacies, chain pharmacies or mass merchandiser pharmacies having a state license to dispense medications to the general public 1: Agree, 2: Disagree (explain): [ Text ]

67. "Sales Tax" means a tax imposed by local, state, or federal government at the point of sale on a Claim that is collected by the dispensing Pharmacy 1: Agree, 2: Disagree (explain): [ Text ]

68. "Single Source Generic(s)" or "SSG(s)" are Generic Drugs that are manufactured by one generic drug manufacturing company. 1: Agree, 2: Disagree (explain): [ Text ]

69. "Special Enrollment Period" means the timeframe when a member can make changes to its Medicare Advantage or Medicare drug coverage when certain life events occur (i.e. moving, loss of other coverage, etc.). 1: Agree, 2: Disagree (explain): [ Text ]

70. “Specialty Drugs” are defined as certain pharmaceuticals, biotech or biological drugs, that are used in the management of complex or genetic disease that meet at least one of the first two criteria (a and b) and all of the last three criteria (c-e) in order to be placed on your specialty drug list:

a) Produced through DNA technology or biological processes

b) Targets a complex disease caused by a combination of genetic, environmental and lifestyle factors

c) Unique handling, distribution, and/or administration requirements such that the drug cannot be safely dispensed from a Mail Order Pharmacy

d) Requires a customized medication management program that includes medication use review, patient training, coordination of care and adherence management for successful use such that more frequent monitoring and training is required

e) Are not a device, supply, medical food, or durable medical equipment.

Lastly, only newly FDA-approved and launched drugs, and drugs not on the market as of the RFP submission date may be considered for addition to the specialty pharmacy drug price list after this date, unless the Specialty Pharmacy gains access to a previously unavailable Limited Distribution Specialty Drug. 1: Agree, 2: Disagree (explain): [ Text ]

71. “Specialty Pharmacy” means (a) an automated Pharmacy that processes prescriptions at one or more central locations and delivers them through the mail or other third-party delivery service to the locations of Members, and does not have a physical Member-facing storefront, (b) the PBM Specialty Pharmacies, (c) a pharmacy that dispenses a Limited Distribution Specialty Drug, and (d) any other Pharmacy that the parties agree in writing is a Specialty Pharmacy for purposes of this definition. If such a Pharmacy dispenses Specialty Drugs and non-Specialty Drugs, such Specialty Pharmacy shall constitute a Specialty Pharmacy only with respect to the dispensing of Specialty Drugs and shall constitute a Mail Pharmacy (in the case of clause (a) of the preceding sentence) or a Retail Pharmacy (in the case of clause (b) and (d) of the preceding sentence) with respect to the dispensing of non-Specialty Drugs. 1: Agree, 2: Disagree (explain): [ Text ]

72. "Specialty Service Fees" means fees collected by a PBM or PBM Affiliates from pharmaceutical companies for certain costs or services associated with stocking, handling and dispensing certain Specialty Drugs, such as distribution data reporting, inventory tracking and management, FDA Risk Evaluation and Mitigation Strategy (REMS) support and enhanced adverse even reporting and coordination. 1: Agree, 2: Disagree (explain): [ Text ]

73. "Step Therapy" means a process where the patient may be required to try a lower cost prescription drug that treats a given condition before "stepping up" to a similar-acting, but more expensive drug. 1: Agree, 2: Disagree (explain): [ Text ]

74. “Subrogation Claim” means 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 Commonwealth/DEI is deemed to be the primary payor by operation of applicable federal or state laws. 1: Agree, 2: Disagree (explain): [ Text ]

75. "Territory Pharmacy" or "TER" means a Retail Pharmacy located in one of the United States territories, i.e. American Samoa, Guam, Northern Mariana Islands, Puerto Rico, United States Virgin Islands. These Pharmacies are identified by an ISO 3166 code (state code) of AS, GU, MP, PR, and VI. 1: Agree, 2: Disagree (explain): [ Text ]

76. "Total Claim Cost" is equal to the Ingredient Cost plus the applicable Dispensing Fee plus the applicable sales tax. 1: Agree, 2: Disagree (explain): [ Text ]

77. "Total Remuneration" is defined as Manufacturer Payments, Other Pharmaceutical Manufacturer Revenue, and includes other discounts or monies attributed to member utilization. 1: Agree, 2: Disagree (explain): [ Text ]

78. “Traditional Pricing” means a financial structure comprised of fixed guaranteed discounts and fees. In this arrangement, PBM retains the difference between (1) Mail Order Pharmacy and Specialty Pharmacy acquisition costs and the amounts guaranteed to Commonwealth/DEI and (2) contracted rates with Retail Pharmacies and the amounts guaranteed to Commonwealth/DEI. PBM passes through all Manufacturer Payments it receives in excess of Commonwealth/DEI’s guaranteed Manufacturer Payments. Retail Pharmacy rates may vary and the amount paid by PBM to the Retail Pharmacy may not be equal to the amount billed to Commonwealth/DEI and PBM shall retain any difference. 1: Agree, 2: Disagree (explain): [ Text ]

79. "Transmission Fees" fees paid by Participating Pharmacies that directly or indirectly arise from Claims or covered drugs dispensed to Commonwealth/DEI Members. These fees shall not constitute pharmacy rebates if a) such fees do not in aggregate exceed $0.15/Claim (b) such fees constitute a fair and reasonable compensation for services actually performed by PBM for a Participating Pharmacy and (c) the receipt and retention of such fees by PBM are in compliance with all applicable laws. 1: Agree, 2: Disagree (explain): [ Text ]

80. “Usual and Customary Price(s)” or “U&C(s)” means the cash price available to the general public as submitted by the Retail Pharmacy for a Claim on the date such Claim is dispensed. A U&C Claim is one in which the Claim is adjudicated at the Usual and Customary Price and always has a Dispensing Fee of $0.00. 1: Agree, 2: Disagree (explain): [ Text ]

81. “Vaccine Administration Fee” means a professional service fee associated with a Member receiving a Vaccine Claim from a Participating Pharmacy. This charge is directly tied to the bona-fide service of vaccine administration vaccine to a Member. 1: Agree, 2: Disagree (explain): [ Text ]

82. “Vaccine Claim(s)” means a Claim in which the dispensed product is a preparation used as a preventative inoculation to confer immunity against a specific disease, usually employing an innocuous form, fragment, toxin, or DNA of the disease agent to stimulate antibody production, and for which the purchase price includes the Ingredient Cost, the Dispensing Fee, the vaccine fee and the cost to administer the vaccine. These Claims are identified with a Medi-Span Generic Product ID (GPI-2) of '17' or '18', or has an AHFS Extended Therapeutic Class Code of 80120000 or 80080000. 1: Agree, 2: Disagree (explain): [ Text ]

83. "Veteran Affairs Pharmacy" or "VA" means a Retail Pharmacy under veteran affairs jurisdiction where drugs are dispensed and pharmaceutical care is provided to enrolled veterans, by licensed pharmacists. These Pharmacies are identified by a National Council for Prescription Drug Program’s (NCPDP’s) dispenser type code of 9. 1: Agree, 2: Disagree (explain): [ Text ]

84. "Value-based Rebates" mean payments collected by PBM or PBM Affiliates from pharmaceutical companies based on whether pharmaceutical companies' drug therapies meet specified targets, patient outcomes, and/or other program efficacy metrics. 1: Agree, 2: Disagree (explain): [ Text ]

85. “Zero Balance Due” or “ZBD Claim" means any Claim where the member pays the total amount of the claim, including any applicable sales tax, and the plan pays zero 1: Agree, 2: Disagree (explain): [ Text ]

Technical

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 ]

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 ]

2: Disagree (explain): [ Text ]

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 ]

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…