Attachment J.5 – WTC Health Program Technical Evaluation Criteria Workbook Performance Guarantees.xlsx
XLSX spreadsheet 217 KB Posted
- Attached to
- WTCHP Pharmacy Benefits Manager Federal contract opportunity
- Solicitation number
- 75D301-21-R-71805
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 75D301-21-R-71805 Revised 04-30-2021.doc | DOC document | |
| Question and Answer Clarifications 75D301-21-R-71805.xlsx | XLSX spreadsheet | |
| 75D301-21-R-71805 Revised 04-26-2021.doc | DOC document | |
| Questions and Answers 75D301-21-R-71805.xlsx | XLSX spreadsheet | |
| 75D301-21-R-71805 Revised 04-19-2021.doc | DOC document | |
| Attachment J.6 CUI-SSP System Security Plan.docx | DOCX document | |
| Attachment J.3 Past Present Performance Questionnaire.docx | DOCX document | |
| Attachment J.2 - Business Associate Agreement.docx | DOCX document | |
| 75D301-21-R-71805.doc | DOC document | |
| Attachment J.1 HHS Subcontracting Plan Template.doc | DOC document | |
| Attachment J.4 Question and Answer Template.xlsx | XLSX spreadsheet |
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Text version
Capabilitites Phase I
| In-house | Available | Yes | 1 | <1% | |||||
| PBM Capabilities - Contracting | Subcontracted | Not offered | No | 2 | 1-5% | ||||
| WTCHP | Not offered | N/A | 3 | 6-10% | |||||
| 4 | >10% | ||||||||
| Company Information | Vendor Response | 5 | |||||||
| Company Name | >5 | ||||||||
| Number of Employees | |||||||||
| Publically traded or privately held | |||||||||
| Annual revenue | |||||||||
| Assets | |||||||||
| Liabilities | |||||||||
| Pharmacy Metrics | |||||||||
| Book of business (Commercial) annual RX trend for the last 3 years | |||||||||
| Specialty | Year 1: Year 2: Year 3: | ||||||||
| non-Specialty | Year 1: Year 2: Year 3: | ||||||||
| Total | Year 1: Year 2: Year 3: | ||||||||
| Book of business aggregate discount, network performance (weighted average AWP discount of amounts paid to network pharmacies across all claims. These aggregates will be assumed bucketed in accordance with financial bid specification responses) | <----Requested for TRADITIONAL bids. Strongly encouraged for PASS-THROUGH bids. | ||||||||
| Retail | Brand: | Generic: | |||||||
| Brand: | Generic: | ||||||||
| Specialty | Brand: | Generic: | |||||||
| Number of lives under management | |||||||||
| Number of prescriptions processed annually | |||||||||
| Number of prescriptions filled through your own facilities/mail (if applicable) | |||||||||
| Number of self-insured companies served | |||||||||
| Number of self-insured lives managed | |||||||||
| Number of Medicaid plans served | |||||||||
| Number of Medicaid lives managed | |||||||||
| Number of Medicare plans served | |||||||||
| Number of Medicare lives managed | |||||||||
| Staffing Metrics | |||||||||
| Number of pharmacists on staff - Mail | |||||||||
| Number of pharmacists on staff - Specialty | |||||||||
| Number of pharmacists on staff - PBM operations/Formulary | |||||||||
| Number of technicians on staff - Mail | |||||||||
| Number of technicians on staff - Specialty | |||||||||
| Number of technicians on staff - PBM/Formulary | |||||||||
| Staffing Metrics cont. (Turnover Percentage) | |||||||||
| Mail/Specialty pharmacist | |||||||||
| PBM operations/formulary pharmacist | |||||||||
| Mail/Specialty technician | |||||||||
| PBM operations/formulary technician | |||||||||
| Clinical account executive | |||||||||
| Account managers | |||||||||
| Sales representatives | |||||||||
| Executives and directors | |||||||||
| Service | Vendor | ||||||||
| (drop down) | Comments - Details | ||||||||
| Disease management | |||||||||
| Claim adjudication | |||||||||
| Eligibility processing and maintenance | |||||||||
| Formulary maintenance | |||||||||
| ID card production | |||||||||
| Member communications | |||||||||
| Mail order pharmacy and fulfillment | |||||||||
| Specialty pharmacy and fulfillment | |||||||||
| Call center - member | |||||||||
| Call center - provider | |||||||||
| Paper claim processing | |||||||||
| Implementation services | |||||||||
| Prior authorization services | |||||||||
| Pharma contracting - Rebates | |||||||||
| Retail pharmacy network management | |||||||||
| Clinical programs- utilization management | |||||||||
| Client Reporting Tools | Vendor | ||||||||
| (drop down) | Comments - Details | ||||||||
| Eligibility updates | |||||||||
| Coverage updates and overrides | |||||||||
| Claim history | |||||||||
| Utilization reports - standard or custom | |||||||||
| Member Portal Tools | Vendor | ||||||||
| (drop down) | Comments - Details | ||||||||
| Refill reminders | |||||||||
| Medication pricing and alternatives | |||||||||
| OTC therapy and interaction reporting | |||||||||
| Member-level drug information online (side effects, intent of therapy, treatment goals, clinical pearls) | |||||||||
| Drug:Drug interaction reporting online | |||||||||
| Brand to generic conversion recommendations and savings estimates | |||||||||
| Access to standard formulary online | |||||||||
| Access to member/client specific formulary online | |||||||||
| Mobile/Tablet applications - Please describe the capabilities offered | |||||||||
| Network pharmacy locator | |||||||||
| Toll free customer service number | |||||||||
| Access to formulary recommendations | |||||||||
| Exclusions and non-preferred drug lists | |||||||||
| Prescriber Tools | Vendor | ||||||||
| (drop down) | Comments - Details | ||||||||
| ePrescribing | |||||||||
| Mobile/Tablet applications - Please describe the capabilities offered | |||||||||
| PBM Platform \ Services | Vendor | ||||||||
| (drop down) | Comments - Details (if green) | ||||||||
| Have you recently (within the last 2 years), or are their plans to acquire or merge with another PBM? | |||||||||
| How many claims adjudication platforms are currently operating? | |||||||||
| If there are plans to consolidate platforms, how many platforms do you anticipate running? | |||||||||
| Are there any system upgrades, operational updates or clinical management updates planned or anticipated in the next 12 to 18 months? | |||||||||
| Do the retail, specialty and mail channels operate on the same platform? | |||||||||
| Can you accept an open refill file and what is the fee? | |||||||||
| Can you accept a historic claims file for SmartPA and step therapy programs and what is the fee? | |||||||||
| Are you able to provide a claims feed to the client and what are the fees? | |||||||||
| Are you able to receive and utilize medical claims information for safety monitoring and disease management and what are the associated fees? | |||||||||
| What percent of claims do you review for payment accuracy? | |||||||||
| What percent of claims from RETAIL pharmacies do you review for entry/processing accuracy? | |||||||||
| What percent of claims from Mail pharmacies do you review for entry/processing accuracy? | |||||||||
| Processing | Vendor | ||||||||
| (drop down) | Comments - Details (if green) | ||||||||
| OTC adjudication | |||||||||
| Day supply limitations for specific drug groups (e.g. Specialty RX) | |||||||||
| Can you process paper claims within 10 days? Please provide detail on how often you process these claims and the frequency that reimbursement is mailed to members | |||||||||
| Network | Vendor | ||||||||
| (drop down) | Comments - Details (if green) | ||||||||
| Can you offer a 90-day retail network? If yes, please describe the number of pharmacies available to members with this option and detail the pricing arrangement (mail pricing?) to the plan sponsor and member. | |||||||||
| Member communications included | Vendor | ||||||||
| (drop down) | Comments - Details (include specific fees if applicable) | ||||||||
| Please indicate which are included as standard communications to new members- | |||||||||
| Welcome letter | |||||||||
| Formulary | |||||||||
| FAQs | |||||||||
| ID Card | |||||||||
| Mail order forms for registration | |||||||||
| Health and wellness material sponsored by vendor | |||||||||
| "Generics-first" promotion | |||||||||
| Are member communications available in languages other than English if needed? | |||||||||
| Call center | Vendor Response | ||||||||
| (drop down if available) | Comments - Details | ||||||||
| How many call centers are available to the client? | |||||||||
| What city/state are the call centers located in? | |||||||||
| What percent of calls are handled outside the U.S.? | |||||||||
| What are the hours of operation for these call centers? | |||||||||
| What are the hours of operation in which a pharmacist is available to a member? | |||||||||
| Are general questions, mail inquiries and specialty inquiries handled by the same call center? If not, please provide details. | |||||||||
| Can members call in and receive assistance prior to the go-live date of the plan? If yes, please provide details on what information will be available and how early they may call in. | |||||||||
| Last year's Average Speed of Answer (ASA) rate- | |||||||||
| Last year's Call Abandonment rate- | |||||||||
| Last year's First Call Resolution rate- | |||||||||
| Are these metrics reported in aggregate or by each call center separately? | |||||||||
| How many hours are new representatives required to obtain prior to working independently? (classroom and preceptorship) | |||||||||
| Which of the following would require an outbound call to the member prior to fulfillment? Please provide details on the threshold if applicable. | |||||||||
| Dollar threshold | |||||||||
| Number of RX threshold | |||||||||
| Controlled substances ($ or number of RX) | |||||||||
| Temperature parameters | |||||||||
| Specialty Medications | |||||||||
| How many times will you attempt to reach the member? | |||||||||
| What happens if no response? | |||||||||
| Please indicate which of the following are available to the customer service representative- | |||||||||
| Eligibility | |||||||||
| Retail network information | |||||||||
| Order status - mail order | |||||||||
| Claim history | |||||||||
| ID card questions | |||||||||
| How do you document call outcomes? | |||||||||
| Are representative required to document outcomes prior to closing the case? | |||||||||
| Will you generate call center reporting for the client based on standard metrics? | |||||||||
| Please indicate whether you perform these types of member satisfaction surveys and provide details around the frequency of these surveys in the far right column | |||||||||
| Telephone | |||||||||
| Internet | |||||||||
| Mail-in | |||||||||
| Which metrics do you survey on? | |||||||||
| CSR encounters | |||||||||
| Mail order turnaround time | |||||||||
| Mail order customer service | |||||||||
| Specialty customer service | |||||||||
| Specialty clinical support | |||||||||
| Network pharmacy access | |||||||||
| Acceptable resolution | |||||||||
| Benefit inquires and plan design |
| CBIZ Benefits && Insurance Services | Pharmacy Request for Proposal |
| &A | Confidential |
&G Page &P of &N &D
Bid Specs (Other) Phase I
| Agree | |
| Agree with exception | |
| Bid Specifications | Disagree |
| WTCHP |
| Bid Requirement (operational) | Vendor Response (drop down) | Explanation for deviation | |
| Carrier connectivity | Vendor must be capable of administering the pharmacy benefit in conjunction with . Bi-directional data feeds for ACA compliance (e.g. deductible/max-out-of-pocket accumulators) must be operational and available to WTCHP at no charge as this is a core requirement to administer PBM services under the ACA. | ||
| Primary PBM functions | Vendor will be responsible for adjudicating prescription drugs claims on behalf, and in accordance with the client's plan design(s). The vendor will be responsible for all drug utilization review, as well as fraud/waste/abuse review at no costs in addition to the base administration fee. Vendor will adjudicate all electronic and paper claims in a timely fashion and have in place internal audits to prevent the mis-billing of any claim. | ||
| POS functions | Vendor agrees their system will allow for WTCHP input of claim overrides, restriction of members to specific drugs/pharmacies/prescribers, and allow for restriction of individual prescribers to specific drug classes if requested | ||
| Data acceptance | Vendor agrees to receive and load any necessary open refill or prior authorization files in addition to an eligibility file during implementation. | ||
| Eligibility | While WTCHP will determine procedures for enrollment and coverage cancellation, vendor accepts responsibility to validate and load all eligibility files upon receipt of a clean data file. Vendor will accept and accurately process the prescription benefit for all eligible members of the plan | ||
| ID Cards | Vendor will adjudicate claims based on eligibility files. ID cards will be provided to all enrolled members during implementation and new members throughout the contract period. These cards will be mailed within 3 days of receipt of a clean eligibility file | ||
| ID Cards continued | Vendor shall allow WTCHP the option to have RX information printed on the members medical ID card | ||
| Mail order pharmacy | If mail service is used; Vendor will be responsible for operating, or contracting with, a mail facility that meets the federal and state regulations to run a pharmacy. Any violations, penalties, or fines will not be passed on to the client. Any costs incurred to expedite an order resulting from an error in the pharmacy operations will not be passed on to the client. | ||
| PPACA compliance | Vendor agrees to conform with all statutes and emerging guidance as a result of PPACA. | ||
| Audit rights | Vendor agrees to allow the client to complete one audit per contract year. The vendor will provide reasonable access MAC rates, formulary rebates and other financial metrics necessary to audit financial performance of the plan. The client will not be responsible for any costs incurred by the PBM to compile the data needed to complete the audit. | ||
| Pharmacy audits | Vendor agrees to continually audit at least 10 network pharmacies utilized by WTCHP members. Vendor will be required to return 100% of recoveries to the client. | ||
| Pharmacy network | Vendor will be required to have a toll-free number available to pharmacies 24/7, 365 days a year for claim processing inquires. Vendor will also be responsible for communicating a network pharmacy termination to the client, and impacted members, at least 90 days prior to that termination date. | ||
| Data sharing | Vendor will allow up to three data feeds to external vendors (e.g. medical carrier, disease management vendor). Vendor should accept any reasonable request for customization of the data feed and frequency of communication based on typical business practices in the industry. | ||
| House generics | In the event a brand drug is substituted and dispensed as a "house generic", in all cases, the member cost share and contractual guarantees of the comparable generic product will be applied. | ||
| In house pharmacy | Vendor agrees to coordinate and partner with any onsite pharmacy (if applicable now, or in the future). This pharmacy shall be considered an in-network pharmacy for the purposes of claims adjudication. | ||
| Bid Requirement (clinical) | Vendor Response (drop down) | Explanation for deviation | |
| Formulary | Vendor agrees that all formulary decisions and clinical protocols will be based on evidence based literature. The formulary and its resultant clinical programs will be designed to offer the member (and their plan sponsor) the most clinically appropriate and cost effective therapy. Up-tiering may only occur a maximum of twice per year. Drugs will never be excluded from the formulary unless required by the FDA or at the request of the plan sponsor. Exclusions occurring at the will of the PBM may be rejected by the plan sponsor and will not have implications on the financial deal in this proposal and subsequently executed in the contract. | ||
| Fiduciary and clinical responsibility | Vendor assumes all fiduciary and clinical responsibility associated with ERISA appeals completed in house. | ||
| Plan design | Vendor agrees they are willing and able to execute the plan design(s) as stated in the plan design section | ||
| Brand to brand conversions | Vendor agrees that brand to brand conversions will only be requested and/or executed pursuant to clinical programs elected by the plan sponsor. | ||
| Clinical program fees | Vendor agrees that any savings achieved from clinical programs will not shared with the vendor in addition to, or in lieu of fees collected for those programs | ||
| Drug utilization review | Vendor agrees that drug utilization review will be standard, and integrated across all channels (retail, mail, specialty, ect) and will include, at a minimum, the following safety edits; drug:drug interactions, drug:disease interactions, validation of dosage, age/gender edits, and monitoring for over/under utilization within a specific class of drugs. | ||
| Specialty - Fulfillment/shipping | Should a medication be deemed unusable due to fulfillment/shipping delays or damage. The medication will be replaced by the vendor at no charge to the member or WTCHP | ||
| Specialty - Refills | Vendor will not auto-refill a specialty medication at anytime. Vendor will only refill a specialty medication pursuant to communication with the member where they are able to determine the subsequent fill is required, the member is responding to therapy and the subsequent fill will not harm the member. | ||
| Specialty - New products | Vendor agrees to communicate new additions to vendor's specialty list within 30 days of FDA approval of that product. WTCHP reserves the right to refuse addition to the specialty list during that notification period. WTCHP reserves the right to review vendors proposed pricing (if available). Should WTCHP believe, with reasonable evidence, the pricing is not market competitive, both parties agree to renegotiate terms in good faith. | ||
| Bid Requirement (other) | Vendor Response (drop down) | Explanation for deviation | |
| Client data - privacy | Vendor agrees not to share WTCHP's data, in detail or in aggregate with out the written approval of WTCHP | ||
| Client data - rights | Vendor agrees to allow WTCHP access to their pharmacy claims data. While it is understood industry and trade privileged information may not be shared, it will be expected that WTCHP may have access to most clinical and financial fields including but not limited to; NDC, date of service, quantity, day supply, ingredient cost, dispensing fee, undiscounted AWP | ||
| Vendor coordination | WTCHP reserves the right to carve out (unbundle) portions of their benefit which could include specific drug classes. Vendor agrees to cooperate with all data sharing, analytics and coordination of benefits on behalf of WTCHP | ||
| Specialty carve-out | Should the plan sponsor choose to contract with a specific vendor for specialty pharmacy management, adjudication and fulfillment the Vendor will provide the necessary data feeds for this transition. The vendor also agrees there will be no adjustments to non-specialty admin fees, discounts, dispensing fees and rebates in response. | ||
| Network contracts | Vendor will allow WTCHP to contract directly with retail pharmacy(s) and will agree to administer their client-specific pricing on a pass-through basis with no revenue to the PBM derived from spread. | ||
| Class action law suits | Vendor agrees to alert the client of any drug related class action law suits which may implicate the client and/or their membership. The vendor will, at no charge, provide the client the necessary data to participate in the class. | ||
| Termination clause | Vendor agrees the client may terminate their agreement with or without cause after notice no less than 90 days in advance | ||
| Vendor commitment during termination | Vendor agrees to pay all owed guarantees, rebates and penalties in the event of termination. Vendor will also provide all necessary documentation and data feeds necessary for transition. Costs incurred for this transition shall not be invoiced to client or used to offset any monies owed to the client. These data feeds include; open refill files, at least 6 months of claims data, and prior authorization records | ||
| Additional pharmacy related vendors | Vendor agrees to allow plan sponsor to engage and/or contract with additional vendors to augment their pharmacy benefit plan. These vendors provider additional services such as Medication Therapy Management (MTM) or member communication to drive consumerism through education around drug and/or pharmacy selection |
| CBIZ Benefits && Insurance Services | Pharmacy Request for Proposal |
| &A | Confidential |
&G Page &P of &N &D
Performance Guarantees
| Agree | ||||
| World Trade Center Health Program (WTCHP) | Agree with exception | |||
| Performance Guarantees | Disagree | |||
| WTCHP | ||||
| Vendor Response | ||||
| (Enter value in first cell and use drop downs below) | Please provide detail |
(no response needed if blacked out)
| What is the total value of the fees at risk for WTCHP | $ - 0 |
| Vendor agrees to track and reconcile all performance guarantees on WTCHP data and not the vendor's book of business as a whole | |
| Vendor agrees to report on all guarantees having fees at risk based on the reporting frequency outlined below for each guarantee | |
| WTCHP may reallocate fees at risk annually | |
| Performance guarantees will be settled on an annual basis and shortfall penalties will be paid to WTCHP within the first quarter after the contract year | |
| Vendor will not use a surplus gain in one performance metric to offset shortfalls in another |
| PBM Service | Expectation | Frequency of reporting | Reconciliation period | Vendor Response | ||
| (drop down) | Please provide detail |
(no response needed if blacked out)
| Implementation | |||
| Vendor will successfully implement the RX benefit plan and member portal systems prior to the go-live date as mutually agreed upon by both parties | Program is operation on go-live date and vendor has met all surrogate deadlines | One time (during implementation process) | One time |
| Vendor will successfully load all eligibility data within 15 days and set-up related file feeds needed for subsequent eligibility data transmission | Pass / Fail | One time (during implementation process) | One time |
| Vendor will test and confirm successful benefit set-up with WTCHP | Pass / Fail | One time (during implementation process) | One time |
| Vendor will successfully obtain and load all claims history and prior authorization data from prior vendor | Pass / Fail | One time (during implementation process) | One time |
| Vendor agrees 99% of new plan participants will be mailed an on-boarding kit (ID cards and welcome materials), no later than 10 days prior to the go-live date, upon receipt of a clean and accurate eligibility file. | 99% within 10 days (business) | One time (during implementation process) | One time |
| WTCHP satisfaction with implementation process. All timelines are met, cards are mailed to correct addresses on time, communication materials are distributed as agreed upon and the benefit is set up to adjudicate claims as specified in the documentation signed off on during implementation. | Pass / Fail | Within 60 days after the effective date | One time |
| Eligibility data (on-going) | |||
| Percent of eligibility files loaded without error within 1 business day. Assumes file error-free file from eligibility vendor | 100% | Monthly | Annually |
| Pwecent of provider files loaded without error within 1 business day. Assumes file error-free file from eligibility vendor. | 100% | Monthly | Annually |
| Retail Network | |||
| Percent of time the claims processing system is available to retail pharmacies to adjudicate claims excluding any predetermined and communicated maintenance outages. | >99.5% | Quarterly | Annually |
| Number of random audits and targeted desk audits conducted annually will be 50 and 100 respectively. | 50/100 | Annually | Annually |
| Number of retail network pharmacies utilized by WTCHP which are audited annually. Minimum of 10 required. | 10 | Quarterly | Annually |
| Percent of mail and specialty pharmacies utilized by WTCHP which are audited annually | 100% | Quarterly | Annually |
| Percent of members with access to a retail pharmacy in their zip code. 3 miles for urban, 10 miles for rural | >98% | Quarterly | Annually |
| PBM Service | Expectation | Frequency of reporting | Reconciliation period | Vendor Response | ||
| (drop down) | Please provide detail |
(no response needed if blacked out)
| Customer service | |||
| Average time that inbound calls to customer service will be answered. Excludes calls routed to IVR. | 20 seconds | Quarterly | Annually |
| Percent of calls in which it takes less than 60 seconds for the member to reach a pharmacist after requesting that transfer from a customer service representative or electing that option from prompts | 100% | Quarterly | Annually |
| Percent of calls answered at the specialty pharmacy (by a live representative) within 30 seconds | 100% | Quarterly | Annually |
| Percent of calls that are not answered by the PBM (abandonment rate) | <2% | Quarterly | Annually |
| Percent of members who do not call back within 1 week of their initial call for the same inquiry (first call resolution) | 90% | Quarterly | Annually |
| Vendor agrees 99% of new plan participants will be mailed an on-boarding kit (ID cards and welcome materials) upon receipt of a clean and accurate eligibility file. | 99% within 5 days (business) | Annually | One time |
| Percent of members who are responded to within 10 days of the PBM's receipt of a written request | 95% | Quarterly | Annually |
| Member survey | ||||||
| Percent of utilizing members who self report some level of satisfaction with their customer service experience based on an annual review. | ≥90% | Annually | Annually | |||
| PBM Service | Expectation | Frequency of reporting | Reconciliation period | Vendor Response | ||
| (drop down) | Please provide detail |
(no response needed if blacked out)
| Account service | |||
| Calls returned by the account team within 1 business day | 95% | Quarterly | Annually |
| Percent of calls and emails resolved within 2 business days | ≥90% | Quarterly | Annually |
| Claims | |||
| The PBM will have the ability to apply all standard UM edits – PA’s, DUR, step therapy, quantity limits, days’ supply limits etc. and others that may optimize medication utilization | 99.5% | Quarterly | Annually |
| Percent of paper claims processed within 10 business days | 90% | Quarterly | Annually |
| Percent of mail and specialty prescriptions dispensed with no error in drug, form, dose, strength, directions, patient pursuant to the written prescription AND delivered to the correct patient address | 99.99% | Quarterly | Annually | |||
| Average turn around time (from receipt of RX to shipped date) for mail and specialty claims upon receipt of a clean prescription order | ≤2 days | Quarterly | Annually | |||
| Average turn around time (from receipt of RX to shipped date) for mail and specialty claims upon receipt of an order requiring additional outreach to the member or physician. After consulting with the prescriber, if it is deemed necessary to not fill the prescription, the member will be notified within the 5 business days as well | ≤5 days | Quarterly | Annually | |||
| Vendor agrees at least 97% of mail order prescription with an equivalent generic will be dispensed as the generic product where substitution is permissible. | 97% | Quarterly | Annually | |||
| PBM Service | Expectation | Frequency of reporting | Reconciliation period | Vendor Response | ||
| (drop down) | Please provide detail |
(no response needed if blacked out)
| Reporting | |||
| Vendor will prepare and report (mutually agreed upon) plan performance metrics on an annual, semi-annual and quarterly basis. Reports will be provided in advance (electronically or hardcopy) within 45 days of the close of the study period | 100% | Quarterly | Annually |
| CBIZ Benefits && Insurance Services | Pharmacy Request for Proposal |
| &A | Confidential |
&G Page &P of &N &D
Credits-Allowances
| Credits / Allowances | |||
| WTCHP | |||
| Please detail any credits/allowances being offered as part of this proposal | |||
| Year 1 | Year 2 | Year 3 | |
| Implementation Credit | |||
| Audit Credit - Pre-implementation | |||
| Audit Credit - Post-implementation or ongoing | |||
| Admin Credit - For clinical programs, mailings, etc. | |||
| Other - Please Describe |
| CBIZ Benefits && Insurance Services | Pharmacy Request for Proposal |
| &A | Confidential |
&G Page &P of &N &D
Financial
| Financial Bid | Lookups: |
| WTCHP | Pricing Deal |
| Traditional | |
| Bidding vendor should complete all cells shaded in green. Bid specifications may be drop down menus while financial inputs are fill-in-the-blank. Discounts should be based off AWP. The vendor may present one or both pricing models (e.g. pass-through, traditional, hybrid). | Pass Through (With minimum guarantees) |
| Pricing compendia used | |||
| Proposed Formulary (name of formulary) | |||
| Formulary Type | |||
| Retail network | |||
| Retail-30 | Open Network | Broad | |
| Pricing Arrangement | Narrow | ||
| Network | |||
| Pre/Post Rollback | |||
| Zero Balance Logic (ZBL) allowed and included | Placement of SSGs for pricing | ||
| U&C included in BRAND discount | Brand | ||
| U&C included in GENERIC discount | Generic | ||
| Single Source Generics included in brand or generic | Separated out |
| Non-Specialty Discounts | Actual NDC | ||
| Brand Guarantee | Year 1 | 0.00% | 100ct and Pints |
| Year 2 | 0.00% | ||
| Year 3 | 0.00% | U&C included | |
| Generic Overall Guarantee | Year 1 | 0.00% | Yes |
| Year 2 | 0.00% | No | |
| Year 3 | 0.00% | ||
| MAC-Generic Discount | Year 1 | 0.00% | ZBL allowed |
| Year 2 | 0.00% | Yes | |
| Year 3 | 0.00% | No | |
| non-MAC Generic Discount | Year 1 | 0.00% | |
| Year 2 | 0.00% | MAC at Mail | |
| Year 3 | 0.00% | Yes | |
| Single Source Generic Discount | Year 1 | 0.00% | No |
| Year 2 | 0.00% | ||
| Year 3 | 0.00% | Specialty - retail lock required | |
| Specialty Discounts | Yes | ||
| Brand Guarantee | Year 1 | 0.00% | No |
| Year 2 | 0.00% | ||
| Year 3 | 0.00% | Rebates | |
| Generic Guarantee | Year 1 | 0.00% | Flat - guaranteed |
| Year 2 | 0.00% | Minimum - guaranteed | |
| Year 3 | 0.00% | ||
| Dispensing Fees (per RX) | |||
| Brand | Year 1 | $ - 0 | |
| Year 2 | $ - 0 | Rebate Basis | |
| Year 3 | $ - 0 | \Brand RX | |
| Generic | Year 1 | $ - 0 | \Formulary Brand RX |
| Year 2 | $ - 0 | \RX | |
| Year 3 | $ - 0 | ||
| Specialty | Year 1 | $ - 0 | Rollback |
| Year 2 | $ - 0 | Pre Roll-back | |
| Year 3 | $ - 0 | Post Roll-back |
| Retail-90 | Admin Fees | |
| Provide differential pricing and network information, if available, for specific retail pharmacies offering deeper discounts for mail-like fills at retail | ||
| Minimum days supply of prescription required for the Retail-90 rate | ||
| Network | PEPM | |
| Pharmacies in proposed retail-90 network (provide name and # of pharmacies) | ||
| Pre/Post Rollback | PMPM | |
| Zero Balance Logic (ZBL) allowed and included | ||
| U&C included in BRAND discount | Mail pricing at retail | |
| U&C included in GENERIC discount | Yes | |
| Single Source Generics included in brand or generic | No |
| Non-Specialty Discounts | Retail Lock for specialty pricing | ||
| Brand Guarantee | Year 1 | 0.00% | Yes |
| Year 2 | 0.00% | No | |
| Year 3 | 0.00% | ||
| Generic Overall Guarantee | Year 1 | 0.00% | Compendia |
| Year 2 | 0.00% | First Databank | |
| Year 3 | 0.00% | MediSpan | |
| MAC-Generic Discount | Year 1 | 0.00% | Other - Please specify |
| Year 2 | 0.00% | ||
| Year 3 | 0.00% | Formulary | |
| non-MAC Generic Discount | Year 1 | 0.00% | Open |
| Year 2 | 0.00% | Closed | |
| Year 3 | 0.00% | Other - Please specify | |
| Single Source Generic Discount | Year 1 | 0.00% | |
| Year 2 | 0.00% | ||
| Year 3 | 0.00% | ||
| Specialty Discounts | |||
| Brand Guarantee | Year 1 | 0.00% | |
| Year 2 | 0.00% | ||
| Year 3 | 0.00% | ||
| Generic Guarantee | Year 1 | 0.00% | |
| Year 2 | 0.00% | ||
| Year 3 | 0.00% | ||
| Dispensing Fees (per RX) | |||
| Brand | Year 1 | $ - 0 | |
| Year 2 | $ - 0 | ||
| Year 3 | $ - 0 | ||
| Generic | Year 1 | $ - 0 | |
| Year 2 | $ - 0 | ||
| Year 3 | $ - 0 | ||
| Specialty | Year 1 | $ - 0 | |
| Year 2 | $ - 0 | ||
| Year 3 | $ - 0 |
| Mail Order | |
| Package size provision | |
| MAC at mail | |
| Day Supply Minimum | |
| Single Source Generics included in brand or generic |
| Non-Specialty Discounts | ||
| Brand Guarantee | Year 1 | 0.00% |
| Year 2 | 0.00% | |
| Year 3 | 0.00% | |
| Generic Overall Guarantee | Year 1 | 0.00% |
| Year 2 | 0.00% | |
| Year 3 | 0.00% | |
| MAC-Generic Discount | Year 1 | 0.00% |
| Year 2 | 0.00% | |
| Year 3 | 0.00% | |
| non-MAC Generic Discount | Year 1 | 0.00% |
| Year 2 | 0.00% | |
| Year 3 | 0.00% | |
| Single Source Generic Discount | Year 1 | 0.00% |
| Year 2 | 0.00% | |
| Year 3 | 0.00% | |
| Dispensing Fees (per RX) | ||
| Brand Guarantee | Year 1 | $ - 0 |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 | |
| Generic Guarantee | Year 1 | $ - 0 |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 |
| Specialty | |
| Assumes Exclusive Specialty ("retail lock") |
| Specialty Discounts | ||
| Brand Guarantee | Year 1 | 0.00% |
| Year 2 | 0.00% | |
| Year 3 | 0.00% | |
| Generic Guarantee | Year 1 | 0.00% |
| Year 2 | 0.00% | |
| Year 3 | 0.00% | |
| Specialty dispensing Fees (per RX) | ||
| Brand and Generic | Year 1 | $ - 0 |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 |
Admin Fees
| Retail | Year 1 | $ - 0 |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 | |
| Paper | Year 1 | $ - 0 |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 | |
| Mail/ Specialty | Year 1 | $ - 0 |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 | |
| PBM Fees | Year 1 | $ - 0 |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 |
| Rebates | |
| Bid Requirement | |
| Basis for rebates |
| Client Rebate Percentage | ||
| Retail & Mail | Year 1 | 0% |
| Year 2 | 0% | |
| Year 3 | 0% | |
| Specialty @ Retail | Year 1 | 0% |
| Year 2 | 0% | |
| Year 3 | 0% | |
| Specialty @ Specialty | Year 1 | 0% |
| Year 2 | 0% | |
| Year 3 | 0% | |
| Incentive plan design | ||
| Retail non-specialty | Year 1 | $ - 0 |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 | |
| Retail Specialty | Year 1 | $ - 0 |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 | |
| Retail-90 | Year 1 | $ - 0 |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 | |
| Year 1 | $ - 0 | |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 | |
| Specialty | Year 1 | $ - 0 |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 | |
| Rebates | ||
| non-Incentive plan design | ||
| Retail non-specialty | Year 1 | $ - 0 |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 | |
| Retail Specialty | Year 1 | $ - 0 |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 | |
| Retail-90 | Year 1 | $ - 0 |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 | |
| Year 1 | $ - 0 | |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 | |
| Specialty | Year 1 | $ - 0 |
| Year 2 | $ - 0 | |
| Year 3 | $ - 0 |
| CBIZ Benefits && Insurance Services | Pharmacy Request for Proposal |
| &A | Confidential |
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Specialty Pharmacy
| Financial Bid - Specialty Pharmacy |
| WTCHP |
In addition to the guaranteed aggregate specialty discount on the previous page, please provide your proposed discounts by drug. Please provide both open, and lock-in pricing if applicable.
| Brand Name | NDC | Open Network Discount | Exclusive - Lock-in Discount |
| XOLAIR SOL 150MG | 50242004062 | 0.00% | 0.00% |
| NUCALA INJ 100MG/ML | 00173089201 | 0.00% | 0.00% |
| TACROLIMUS CAP 1MG | 16729004201 | 0.00% | 0.00% |
| MYCOPHENOLAT TAB 500MG | 64380072507 | 0.00% | 0.00% |
| TACROLIMUS CAP 0.5MG | 16729004101 | 0.00% | 0.00% |
| SPRYCEL TAB 100MG | 00003085222 | 0.00% | 0.00% |
| XTANDI CAP 40MG | 00469012599 | 0.00% | 0.00% |
| TAGRISSO TAB 80MG | 00310135030 | 0.00% | 0.00% |
| FASENRA INJ 30MG/ML | 00310173030 | 0.00% | 0.00% |
| POMALYST CAP 4MG | 59572050421 | 0.00% | 0.00% |
| VENCLEXTA TAB 100MG | 00074057622 | 0.00% | 0.00% |
| OFEV CAP 150MG | 00597014560 | 0.00% | 0.00% |
| IBRANCE CAP 125MG | 00069018921 | 0.00% | 0.00% |
| NINLARO CAP 4MG | 63020008002 | 0.00% | 0.00% |
| GLEEVEC TAB 400MG | 00078064930 | 0.00% | 0.00% |
| MYCOPHENOLAT CAP 250MG | 00054016325 | 0.00% | 0.00% |
| TASIGNA CAP 150MG | 00078059287 | 0.00% | 0.00% |
| XOLAIR INJ 75/0.5 | 50242021401 | 0.00% | 0.00% |
| ZYTIGA TAB 500MG | 57894019506 | 0.00% | 0.00% |
| NEXAVAR TAB 200MG | 50419048858 | 0.00% | 0.00% |
| CALQUENCE CAP 100MG | 00310051260 | 0.00% | 0.00% |
| NEULASTA INJ 6MG/0.6M | 55513019001 | 0.00% | 0.00% |
| VOTRIENT TAB 200MG | 00078067066 | 0.00% | 0.00% |
| IBRANCE CAP 100MG | 00069018821 | 0.00% | 0.00% |
| CYCLOPHOSPH CAP 50MG | 54879002201 | 0.00% | 0.00% |
| CBIZ Benefits && Insurance Services | Pharmacy Request for Proposal |
| &A | Confidential |
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Bid Specifications (financial)
| Agree | |
| Agree with exception | |
| Bid Specifications | Disagree |
| WTCHP | N/A |
All financial bids on the [financial] tab shall be inclusive of all fees associated with the PBM work in this contract. Terms on the [financial] tab will be assessed in conjunction with each vendor's response to the financial bid specifications below. Deviations may result in adjustments to the financial scoring or disqualification.
| Bid Requirement (financial) | Vendor Response (drop down) | Explanation for deviation | ||
| Brand discount guarantee | ||||
| Vendor offers an annual brand discount guarantee which will NOT include claims priced based on usual and customary charges or at a maximum allowable cost (MAC) rate. | ||||
| Generic discount guarantee | ||||
| Vendor offers an annual generic discount guarantee which will NOT include claims priced based on usual and customary charges, but will include all MAC and non-MAC generics. | ||||
| Rebate guarantee | ||||
| Vendor may elect the basis of rebate guarantee on the [financial] tab. Vendor agrees this election will include all claims on that basis regardless of exclusivity, short supply issues or claims paid 100% by the member. | ||||
| Retail pass through | ||||
| Vendor offers to pass through 100% of the value of the contracted reimbursement discount/rate including discounts, MAC rates and dispensing fees on a per/RX basis. Pass through pricing is available on all drugs covered by the plan dispensed through the retail channel. The PBM shall not retain any monies as "spread" and will not subsidize any guarantee with that from another. | ||||
| Retail pass through | ||||
| Vendor attests the amounts received by the dispensing pharmacy as reimbursement will equal the amount paid by the plan sponsor on each claim. | ||||
| Retail contract transparency | ||||
| Vendor will share, at WTCHP's request, any network pharmacy's contracted discount, MAC reimbursement rates and/or dispensing fee at any time during the contract term. | ||||
| Retail contract transparency | ||||
| Vendor will share, at WTCHP's request, any contracts with a specific, or chain of network pharmacies | ||||
| Brand discount minimum guarantee | ||||
| Vendor offers an annual brand minimum discount guarantee which will NOT include claims priced based on usual and customary charges or at a maximum allowable cost (MAC) rate. | ||||
| Generic discount minimum guarantee | ||||
| Vendor offers an annual generic minimum discount guarantee which will NOT include claims priced based on usual and customary charges, but will include all MAC and non-MAC generics. | ||||
| Brand guarantee | Brand guarantees will include; single source brands, multi source brands, and over-the-counter drugs. | |||
| Generic guarantee | Generic guarantees will include; single and multi source generic products regardless of their inclusion on the MAC list, multi-source brands not filled using a DAW code equal to 1 or 2, generics in patent litigation, generics in short supply, generic specialty drugs, and over-the-counter products. These same guarantees will exclude; claims priced at a pharmacy's usual and customary rate, 340b claims, LTC claims, home infusion claims, VA claims, compounds, paper claims, in-house pharmacy claims, and claims where the vendor paid as the secondary/COB payer. | |||
| Absence of signed contract | Vendor agrees that all pricing terms outlined in the proposal or subsequent best and final offers will apply upon the initiation of the benefit under the awarded vendor even in the absence of a signed contract at that time | |||
| Consistent application of pricing terms | Besides rebates, vendor agrees that pricing terms will apply to all members regardless of plan design | |||
| Consistent application of AWP and methodologies | Vendor agrees to use one database/compendia for the purposes of obtaining AWP data and identifying brand, generic and multisource products. Vendor will use the same methodologies and database to reconcile guarantees to actual plan performance | |||
| Market check | Vendor will offer revised financial terms at 18 months into the executed contract based on current market conditions at that time. If WTCHP determine these terms are not competitive, WTCHP reserves the right to terminate the contract without penalty | |||
| Enrollment Increase | Vendor agrees to offer improved financial terms if WTCHP's enrollment increases by 20% or more. Improvements will shall apply on the date enrollment increased to 120% or more. | |||
| Minimum terms | All pricing terms will be accepted as the "minimum" term and cannot be decreased at any point throughout the duration of the contract | |||
| AWP | AWP is defined as the Average Wholesale Price (AWP) published by MediSpan, active on the processing date of the claim, using the full 11-digit NDC of the particular drug /product dispensed. | |||
| Repackagers | Vendor will not use an AWP higher than that of the original manufacturer's AWP as the basis of adjudication of any repackaged product | |||
| Price benchmarks | Should the vendor choose another basis (e.g. transition from AWP to WAC or AAC) of determining ingredient cost, WTCHP will be given a minimum of 90 days notice and details surrounding the change. The vendor will also be responsible for providing an analysis illustrating the revised methodology will be in the favor of, or cost neutral to WTCHP | |||
| Maximum Allowable Cost (MAC) | Vendor shall utilize a MAC reimbursement program for frequently utilized multisource products. These rates shall be the same used at mail and retail channels and the rates will be disclosed to WTCHP upon request. These rates will be competitive with generic programs offered to cash paying guests at some retailers (e.g. Target, Wal-Mart $4 list) The MAC rates used to charge WTCHP must have changes which correlate in magnitude to those rates which are used to reimburse pharmacies specifically instances when a generic product loses exclusivity. | |||
| Separation of pricing and clinical programs | Vendor agrees that pricing agreements submitted (discounts/dispensing fees/rebates) are not tied to participation in any clinical programs such as Prior Authorization, Step Therapy, generics first or mandatory mail. Drug pricing will not be contingent on participation in any program. | |||
| AWP Implications | Vendor agrees that claims will adjudicate and discounts will be reconciled against post-rollback AWP conditions. | |||
| Aggregate guarantees | Vendor agrees that aggregate annual discount guarantees will be computed and reconciled on an all-in basis. Generic discounts will include all MAC and non-MAC products as well as multisource and single source generic products. These guarantees however, will exclude usual and customary as well as zero-balance claims (member pays 100%). | |||
| Financial shortfalls | Any shortfalls in financial guarantees will be paid to the client at an amount equal to, and no less than the financial impact to the client. | |||
| Guarantees are mutually exclusive | Vendor agrees that financial guarantees are measured and reconciled in a mutually exclusive manner and shortfalls in one area may not be offset by surpluses in another. Additionally, rebates may not be included in the discount reconciliation. | |||
| Payment of shortfalls | Vendor agrees to reconcile and provide payment of any shortfalls to the client within 90 days of the annual period. | |||
| Retail Pharmacy Adjudication | Vendor will adjudicate claims at retail using the lower of; (1) contracted discount, (2) the maximum allowable cost, or (3) the usual and customary price submitted by the pharmacy. Dispensing fees will not be applied to claims paid at a usual and customary price. Pricing data will be applied for the particular date of service of each claim. | |||
| Mail Pharmacy Adjudication | Vendor will adjudicate claims at mail using the lower of; (1) contracted discount, or (2) the maximum allowable cost, plus a dispensing fee (if applicable). Pricing data will be applied for the particular date of service of each claim. | |||
| Lower of logic | Vendor agrees that all claims will adjudicate using a lower of logic based on discount, maximum allowable cost or the usual and customary price submitted by the pharmacy. The member shall never pay more than the usual and customary price submitted even if the plan design suggests a higher cost share. | |||
| Zero balance claims | WTCHP will have no financial responsibility on any claim paid 100% by the member including those at mail order. | |||
| MAC pricing | Vendor will use the same MAC pricing for retail pharmacies that it uses at mail | |||
| Mail MAC lower | Should MAC rates differ at mail and retail, the MAC rate for any given drug shall be lower at mail than retail | |||
| Postage increases | Postage increases shall not be passed on to the client. This applies to mail fulfillment and member communications alike | |||
| Compounded drugs | Compounded drugs will be priced using the same logic as other fills at mail and retail. There will be no additional costs or augmented dispensing fees associated with compounded products. | |||
| Mail member cost share | The member cost share at mail must be the cost share defined by the plan design and there will not be a price floor for mail fills applied to the member cost share | |||
| Specialty pricing at retail | Vendor will price specialty drugs at retail based on the contracted and respective guaranteed brand and generic rates at retail. | |||
| Mail / Specialty pricing | Mail and specialty pricing will be in effect for all claims filled at their respective mail and specialty facilities regardless of day supply | |||
| Mail / Specialty collection | Member cost share not collected by the mail or specialty pharmacy will not be charged to WTCHP | |||
| Specialty list - New adds | Vendor agrees that only new products will be included on the specialty list. Drugs previously considered non-specialty will not be added to the list. | |||
| Generic to brand substitution | Vendor agrees that multisource brand products will only be dispensed pursuant to an appropriate DAW code. In the case a multisource brand drug is dispensed absent the request of the patient (DAW=2) or physician (DAW=1), the plan sponsor and member shall pay the contracted generic rate and cost share, and the claim will be included in the generic discount reconciliation. This includes claims billed using DAW 3, 4, and 5 where the pharmacist and/or pharmacy have indicated the generic to brand conversion. | |||
| Administrative fees | Administrative fees are applied to paid claims only and will not include reversals or denied claims. | |||
| Rebate payment | Minimum rebate guarantees will be paid to the client within 90 days at the end of each contract quarter. | |||
| Rebate reconciliation | Rebates will be reconciled and paid to the client within 120 days following the end of each contract year. | |||
| Rebate calculation | Rebates contracted on a claim calculation shall include all claims adjudicated for the plan and will not exclude those paid at 100% member cost share. Rebate calculations will also not exclude any claims based on day supply. | |||
| Rebates defined | The term rebates will include all monies received by PBM from a manufacturer. This will include, but is not limited to; market share incentives, access fees, credits, educational disbursements, marketing grants and charge backs from a mail facility. | |||
| Rebates - Formulary determination | Vendor agrees that guaranteed rebate amounts may not be reduced due to unexpected patent litigations, product withdrawals, recalls, product launches, or for any updates made to the formulary by the vendor during the life of the contract. | |||
| Pricing source - Updates and changes | Vendor agrees that should a change in pricing benchmarks or the source of the pricing data due to marketplace changes or internal decisions, the vendor will; (1) provide the client advance notice (60 days) of the change, (2) reconcile any impacts through a 3rd party audit group, (3) pass through any lower gross costs to the client through deeper discount guarantees. The client will not be responsible for any fixed costs incurred by the PBM to update their systems. | |||
| Specialty definition | Vendor agrees to the following definition of a specialty drug: A specialty drug may have two or more of the following characteristics: | |||
| -Biotech or biological drug | ||||
| -Produced through DNA technology or biological processes | ||||
| -Complex therapy for complex disease | ||||
| -High Cost | ||||
| -Requires special handling\shipping\storage | ||||
| -Require frequent monitoring or specialized patient training | ||||
| -Limited distribution |
| CBIZ Benefits && Insurance Services | Pharmacy Request for Proposal |
| &A | Confidential |
&G Page &P of &N &D
Additional Requests
| Additional Requests | |
| WTCHP | |
| Please provide the following documentation and/or drug lists. If these items are not available or inaccessible, please provide an explanation | |
| Program | Explanation |
| Specialty list | |
| Geoaccess reporting (urban = 1mi, suburban = 5mi, rural = 15mi) | |
| Formulary disruption |
| CBIZ Benefits && Insurance Services | Pharmacy Request for Proposal |
| &A | Confidential |
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File details come from the government source that posted it. Updated .