Attachment Q_Pharmacy Clinical Programs.xlsx
XLSX spreadsheet 58 KB Posted
- Attached to
- RFP for Medical & Pharmacy Benefits
- Solicitation number
- S-44300-00014758
- Issued by
- Marion County, Oregon
About this file
This is a pharmacy clinical programs attachment supporting the Oregon Public Employees' Benefit Board (PEBB) Request for Proposal for comprehensive medical and pharmacy benefits services. The file details clinical program offerings and specifications that vendors must address as part of their pharmacy benefits proposals. The RFP requires vendors to develop and implement clinical programs that support PEBB members' pharmacy needs, with proposals due November 14, 2025. The procurement encompasses detailed plan design specifications, member census data, historical claims information, and comprehensive pharmacy benefit program requirements that bidders must analyze and address in their submissions.
The attachment serves as a reference document for vendor evaluation of pharmacy clinical program effectiveness and capabilities. Vendors are expected to demonstrate robust clinical program infrastructure, including disease management programs, medication therapy management, clinical decision support systems, and other evidence-based interventions designed to improve member health outcomes and manage pharmacy costs. The RFP emphasizes the importance of clinical programs in the overall evaluation of pharmacy benefits proposals, with vendors required to show how their clinical capabilities will serve PEBB's diverse membership population. The procurement process is being conducted entirely through Proposal Technologies Network, Inc.'s online platform via OregonBuys, with specific provisions for diverse business participation and certification requirements outlined in separate RFP attachments.
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Kaiser Clinical Client: Oregon Public Employees Benefit Board (PEBB) Incumbent Vendor: Kaiser Permanente
| Current Clinical Program Detail |
| Vendor comments, if any: |
| Program Name | In place during 2024? | In place during 2025? | |||
| Safety Edits: | |||||
| • | Concurrent DUR | Drug Utilization Review | Yes | Yes | |
| • | Retrospective DUR | Drug Utilization Review | Yes | Yes | |
| • | Fraud, Waste and Abuse Management | Fraud, Waste and Abuse Management | Yes | Yes | |
| • | Controlled Substance Management Programs | Yes | Yes | ||
| • | Safety Programs | Yes | Yes | ||
| Clinical Rules | |||||
| Quantity limitation system edits and support | Quantity Limts | Yes | Yes | ||
| Prior authorization (PA) edits and support | Prior Authorization | Yes | Yes | ||
| Drug exclusions (not as a result of formulary exclusions): | |||||
| • | Brand-Name drugs for which Generic is available, unless approved through prior authorization | Yes | Yes | ||
| • | Over-the-Counter (OTC) drugs unless the product is identified as covered in the Plan Evidence of Coverage | Yes | Yes | ||
| • | Drugs that are not FDA approved | Yes | Yes | ||
| • | Drugs to treat sexual dysfunction | Yes | Yes | ||
| • | Drugs used for weight management | Yes | Yes | ||
| • | Drugs used to enhance athletic performance | Yes | Yes | ||
| • | Extemporaneously compounded drugs, unless the formulation is approved by our Regional Formulary and Therapeutics Committee | Yes | Yes | ||
| • | Nutritional supplements | Yes | Yes | ||
| Step therapy: generic first | |||||
| • | N/A - Step therapy concepts are built into clinical criteria in the Prior Authorization process. | N/A | N/A | N/A | |
| Step therapy: generic or preferred brand first | |||||
| • | N/A - Step therapy concepts are built into clinical criteria in the Prior Authorization process. | N/A | N/A | N/A | |
| Step therapy: preferred brand first | |||||
| • | N/A - Step therapy concepts are built into clinical criteria in the Prior Authorization process. | N/A | N/A | N/A | |
| Duration of Therapy Limits | |||||
| • | N/A - no duration of therapy limits | N/A | N/A | N/A | |
| Dose Optimization (including programs targeting medications billed through pharmacy or through medical | Yes | Yes | |||
| • | |||||
| Split-Fill Programs | |||||
| Compound Management Strategies | |||||
| Yes | Yes | ||||
| Clinical Programs | |||||
| Formulary Options | Yes | Yes | |||
| Drug Category Exclusions | |||||
| Therapeutic Interchange | Yes | Yes | |||
| Gaps in Care/Adherence | Yes | Yes | |||
| Care Engines | Yes | Yes | |||
| Specialty Programs | Yes | Yes | |||
| Genetic Testing | Yes | Yes | |||
| Disease Management/ Medication Therapy Management | Yes | Yes | |||
| Zero Dollar Copay | |||||
| DAW Intervention | Yes | Yes | |||
| Preventive Medications for HDHP | N/A | N/A | |||
| ACA Medication Coverage | Yes | Yes | |||
| Physician Profiling Report Cards | Yes | Yes | |||
| Oncology Pathway Programs | Yes | Yes | |||
| Other Clinical Programs | |||||
| Channel Management Programs | |||||
| Mail Order Programs/90 Day Retail/Exclusive Specialty | Yes | Yes | |||
| Narrow Network | Yes | Yes | |||
| Site of Care Redirection | Yes | Yes | |||
| Self-Administered/Infused Drug Exclusions | Yes | Yes | |||
| Medical Channel Management | Yes | Yes | |||
| GLP-1 Management | |||||
| Diabetes GLP-1 Management Program (D GLP-1 Program) |
Provide a description in column F, including the following:
- Administered by point solution vendor or PBM?
- Mandatory or Voluntary?
- Any unique member cost sharing?
| - Is step therapy required? If so, please detail. | Yes | Yes | |||
| All Other | |||||
| • | Clinical program update or change notification to members (please provide timeline of advance communications) | Yes | Yes | ||
| • | Targeted clinical program mailings to members | Yes | Yes | ||
| Please list ALL other programs: |
Vendor comments, if any:
PEBB Medical & Pharmacy Benefit RFP OregonBuys Bid No. S-44300-00014758 Attachment Q Pharmacy Clinical Programs
Moda Clinical Client: Oregon Public Employees Benefit Board (PEBB) Incumbent Vendor: Moda
| Current Clinical Program Detail |
| Vendor comments, if any: |
| Program Name | In place during 2024? | In place during 2025? | ||||
| Safety Edits: | ||||||
| • | Concurrent DUR | Concurrent DUR | Y | Y | ||
| • | Retrospective DUR | Retrospective DUR | Y | Y | ||
| • | Fraud, Waste and Abuse Management | FWA | Y | Y | ||
| • | Controlled Substance Management Programs | Moda Opioid Utilization and Safety Evaluation | Y | Y | ||
| • | Safety Programs | SMART Program | Y | Y | ||
| Clinical Rules | ||||||
| Quantity limitation system edits and support | Y | Y | ||||
| Prior authorization (PA) edits and support | Y | Y | ||||
| Drug exclusions (not as a result of formulary exclusions): | Y | Y | ||||
| Step therapy: generic first | N | N | ||||
| Step therapy: generic or preferred brand first | Step Therapy edit | Y | Y | |||
| Step therapy: preferred brand first | N | N | ||||
| Duration of Therapy Limits (including programs targeting medications billed through pharmacy or through medical) | N | N | ||||
| Dose Optimization (including programs targeting medications billed through pharmacy or through medical | ||||||
| • | Quantity level limitations - Pharmacy | Quantity level limitation utilization management edit | Y | Y | ||
| • | Drug Wastage program - Medical | Dose Wastage program | Y | Y | ||
| • | Dose Differential program - Medical | Dose Differential program | Y | Y | ||
| • | Weight-Based Dose Optimization program - Medical | Weight-Based Dose Optimization prgram | Y | Y | ||
| • | Split-Fill Programs | Split-Fill program | Y | Y | ||
| • | Compound Management Strategies | |||||
| Compound management | Y | Y | ||||
| Clinical Programs | ||||||
| Formulary Options | High-performance formulary | Y | Y | |||
| Drug Category Exclusions | Refer to the third section above under "clinical rules" | Y | Y | |||
| Therapeutic Interchange | N/A | |||||
| Gaps in Care/Adherence | Retrospective Medication Use Evaluation | Y | Y | |||
| Care Engines | N/A | |||||
| Specialty Programs | Preferred specialty pharmacy | Y | Y | |||
| Genetic Testing | PGx Testing | N | N | |||
| Disease Management/ Medication Therapy Management | Statin Use in Persons with Diabetes | Y | Y | |||
| Zero Dollar Copay | Affordable Care Act | Y | Y | |||
| DAW Intervention | DAW differential | Y | Y | |||
| Preventive Medications for HDHP | N/A | |||||
| ACA Medication Coverage | Affordable Care Act | Y | Y | |||
| Physician Profiling Report Cards | Prescriber Report Card | N | N | |||
| Oncology Pathway Programs | N/A | |||||
| Other Clinical Programs | ||||||
| Med Alerts | Med Alerts (Concurrent DUR) | Y | Y | |||
| High Cost Generics program | High Cost Generics | Y | Y | |||
| Rebate managment | Rebate management | Y | Y | |||
| Value Tier program | Value Tier program | Y | Y | |||
| Site of Care program | Site of Care Program | Y | Y | |||
| Pharmacy Benefit Optimization program | Pharmacy Benefit Optimization program | Y | Y | |||
| Channel Management Programs | ||||||
| Mail Order Programs/90 Day Retail/Exclusive Specialty | Network | Y | Y | |||
| Narrow Network | ArrayRx Core Network | Y | Y | |||
| Site of Care Redirection | Site of Care Program | Y | Y | |||
| Self-Administered/Infused Drug Exclusions | Pharmacy Benefit Optimization | Y | Y | |||
| Medical Channel Management | Medical Pharmacy UM | Y | Y | |||
| GLP-1 Management | ||||||
| Diabetes GLP-1 Management Program (D GLP-1 Program) |
Provide a description in column F, including the following:
- Administered by point solution vendor or PBM?
- Mandatory or Voluntary?
- Any unique member cost sharing?
| - Is step therapy required? If so, please detail. | Required Diagnosis edit | Y | Y | |||
| All Other | ||||||
| Clinical program update or change notification to members (please provide timeline of advance communications) | Quarterly Changes | Y | Y | |||
| Targeted clinical program mailings to members | Retrospective Medication Use Evaluation | Y | Y | |||
| Please list ALL other programs: | ||||||
| • | Clinical Rule: Restricted Diagnosis system edit | Restricted Diagnosis edit | Y | Y |
Vendor comments, if any:
Providence Clinical Client: Oregon Public Employees Benefit Board (PEBB) Incumbent Vendor: Providence
| Current Clinical Program Detail |
| Vendor comments, if any: |
| Program Name | In place during 2024? | In place during 2025? | |||
| Safety Edits: | |||||
| • | Concurrent DUR | There is not a separate name for this program. | Yes | Yes | |
| • | Retrospective DUR | There is not a separate name for this program. | Yes | Yes | |
| • | Fraud, Waste and Abuse Management | There is not a separate name for this program. | Yes | Yes | |
| • | Controlled Substance Management Programs | There is not a separate name for this program. | Yes | Yes | |
| • | Safety Programs | There is not a separate name for this program. | Yes | Yes | |
| Clinical Rules | |||||
| Quantity limitation system edits and support | Yes | Yes | |||
| Prior authorization (PA) edits and support | Yes | Yes | |||
| Drug exclusions | Yes | Yes | |||
| Step therapy: generic first | Yes | Yes | |||
| Step therapy: generic or preferred brand first | Yes | Yes | |||
| Step therapy: preferred brand first | Yes | Yes | |||
| Duration of Therapy Limits (including programs targeting medications billed through pharmacy or through medical) | Yes | Yes | |||
| Dose Optimization (including programs targeting medications billed through pharmacy or through medical | Yes | Yes | |||
| Split-Fill Programs | There is not a separate name for this program. | N/A | N/A | ||
| Compound Management Strategies | |||||
| There is not a separate name for this program. | Yes | Yes | |||
| Clinical Programs | |||||
| Formulary Options | There is not a separate name for this program. | Yes | Yes | ||
| Drug Category Exclusions | There is not a separate name for this program. | Yes | Yes | ||
| Therapeutic Interchange | There is not a separate name for this program. | Yes | Yes | ||
| Gaps in Care/Adherence | There is not a separate name for this program. | N/A | N/A | ||
| Care Engines | There is not a separate name for this program. | Yes | Yes | ||
| Specialty Programs | There is not a separate name for this program. | Yes | Yes | ||
| Genetic Testing | There is not a separate name for this program. | Yes | Yes | ||
| Disease Management/ Medication Therapy Management | There is not a separate name for this program. | Yes | Yes | ||
| Zero Dollar Copay | There is not a separate name for this program. | N/A | NA | ||
| DAW Intervention | There is not a separate name for this program. | No | Yes | ||
| Preventive Medications for HDHP | Value Drug List Program | Yes | Yes | ||
| ACA Medication Coverage | There is not a separate name for this program. | Yes | Yes | ||
| Physician Profiling Report Cards | There is not a separate name for this program. | Yes | Yes | ||
| Oncology Pathway Programs | There is not a separate name for this program. | Yes | Yes | ||
| Other Clinical Programs | Managed Care Savings | Yes | Yes | ||
| Other Clinical Programs | There is not a separate name for this program. | Yes | Yes | ||
| Channel Management Programs | |||||
| Mail Order Programs/90 Day Retail/Exclusive Specialty | There is not a separate name for this program. | Yes | Yes | ||
| Narrow Network | There is not a separate name for this program. | N/A | N/A | ||
| Site of Care Redirection | Site of Care Program | Yes | Yes | ||
| Self-Administered/Infused Drug Exclusions | Self-Administered Drug Program | Yes | Yes | ||
| Medical Channel Management | There is not a separate name for this program. | Yes | Yes | ||
| GLP-1 Management | |||||
| Diabetes GLP-1 Management Program (D GLP-1 Program) |
Provide a description in column F, including the following:
- Administered by point solution vendor or PBM?
- Mandatory or Voluntary?
- Any unique member cost sharing?
| - Is step therapy required? If so, please detail. | There is not a separate name for this program. | Yes | Yes | |||
| All Other | ||||||
| Clinical program update or change notification to members (please provide timeline of advance communications) | There is not a separate name for this program. | Yes | Yes | |||
| Targeted clinical program mailings to members | There is not a separate name for this program. | Yes | Yes | |||
| Please list ALL other programs: | ||||||
| • | Narrow Network R90 and mail order for maintenance and value drugs | Narrow Network R90 and Mail order for Maintenance Medications and Value Drug List | N/A | N/A | ||
| • | Medical Claims Editing Program | Medical Claims Editing Program | Yes | Yes | ||
| • | Payment Integrity Program | Payment Integrity Program | Yes | Yes | ||
| • | Over The Counter (OTC) Program | Over The Counter (OTC) Program | Yes | Yes | ||
| • | Real Time Benefit Tool | Real Time Benefit Tool | Yes | Yes | ||
| • | Appeals & Grievances | There is not a separate name for this program. | Yes | Yes | ||
| • | Rx Saving Solution | Rx Saving Solution | No | Yes | ||
| • | Help Script Copay Maximizer Program | Help Script Copay Maximizer Program | Yes | Yes | ||
| • | Progyny Fertility Services | Progyny Fertility Services | N/A | Yes | ||
| • | Transitions of Care Program | There is not a separate name for this program. | Yes | Yes | ||
| • | Value Based Care Agreements | There is not a separate name for this program. | Yes | Yes | ||
| • | Tailored Specialty Case Review for High Cost Medications | There is not a separate name for this program. | Yes | Yes | ||
| • | Specialized Drug Utilization Reviews | There is not a separate name for this program. | Yes | Yes | ||
| • | Biosimilar First Program | There is not a separate name for this program. | Yes | Yes | ||
| • | Specialty Pharmacy Rescue Refill Reminder | Rescue Refill Reminder | Yes | Yes |
Vendor comments, if any:
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