Attachment Q – Pharmacy Questionnaire.docx

Request for Proposal – Prescription Benefit Management Services Gloucester County Public Schools (GCPS)

Thank you for taking the time to complete and submit the following Request for Proposal (RFP). This RFP is coordinated through USI Insurance Services Pharmacy Consulting for an implementation date of 10/1/2026.

Your completed response will be utilized to determine the overall value of your Pharmacy Benefit Management (PBM) services in relation to our expectations of PBM’s that we would recommend to our client.

It is important to emphasize that a major component of this RFP is the establishment of a fixed dollar per unit fee schedule for generic drugs.

TABLE OF CONTENTS

1. GCPS Overview

2. SECTION I – RFP TERMS AND CONDITIONS

3. SECTION II – RESPONDENT INFORMATION

4. SECTION III – IMPLEMENTATION PLAN

5. SECTION IV – ADMINISTRATIVE FEES

6. SECTION V – CLAIM PROCESSING SERVICE

7. SECTION VI – ACCOUNT SERVICE

8. SECTION VII – MEMBER SERVICES

9. SECTION VIII – PHARMACY NETWORK

10. SECTION IX – PHARMACY NETWORK MANAGEMENT AND QUALITY ASSESSMENT

11. SECTION X – PRESCRIPTION DRUG REIMBURSEMENT

12. SECTION XI – GENERIC DRUG MAXIMUM ALLOWABLE CHARGE (MAC) PROGRAM

13. SECTION XII – REPORTING/DATA FEEDS

14. SECTION XIII – FORMULARY PROCEDURE

15. SECTION XIV – FORMULARY REBATES

16. SECTION XV – CLINICAL PROGRAMS

17. SECTION XVI – SPECIALTY DRUG PRICING AND MANAGEMENT

18. Appendix B – Financial Summary

19. Appendix C – Performance Guarantees

20. Appendix D – Summary of Key Issues

GCPS Overview

ENROLLMENT

Please refer to Medical RFP for this information.

BENEFIT OVERVIEW*

Please refer to Medical RFP for this information.

CLAIM SUMMARY

Please refer to Medical RFP for this information.

SECTION I

RFP TERMS AND CONDITIONS

INFORMATION REQUIREMENTS

A. Respondent must submit complete responses to this RFP. Each response should provide a clear, concise and complete description of Respondent’s strategy and ability to meet the project requirements outlined in this RFP. The pricing each Respondent submits must include full unit cost information. Proposals not including a generic unit cost guarantee will be considered incomplete and may not be eligible for consideration.

B. An officer or other official of the Respondent's firm who has legal authority to commit the firm to performance of the proposed services must sign the information marked as the "original" information as indicated in Section IV – Administrative Fees.

C. Respondent’s pricing must be firm as proposed and encompass all costs and expenses, including all supplies for the administration of the program, including all shipping costs to Client but not limited to, all labor (including overtime) and materials required to complete or provide service within the specified time frames, all applicable state, federal and local taxes (including sales and use taxes), and all other costs and expenses required to complete or operate the project.

D. If Respondent proposes the use of subcontractors or skilled trade groups to complete any part of the work, Respondent’s information must include a list which discloses each subcontractor’s name, address, contact person. Respondent must also include a complete description of subcontracted work and an explanation of the subcontractor’s qualifications and experience. Include this information in Section II, "Respondent Information".

SECTION II

RESPONDENT INFORMATION

Company Name___________________________________________________

List location(s) of the company offices and location of the office servicing the account.

Name, address and telephone number(s) of the Respondent’s point of contact for a contract resulting from this RFP

Primary Contact

Name:

Title:

Address:

City:

State:

Zip:

Telephone #:

Fax Phone #:

E-mail Address:

Secondary Contact

Name:

Title:

Address:

City:

State:

Zip:

Telephone #:

Fax Phone #:

E-mail Address:

A. Company background/history, including owners with a share greater than 5%, and why the Respondent is qualified to provide the services described in this RFP.

B. Length of time Respondent has been providing services described in this RFP. Provide a brief description of business focus and growth over past five years (2020-2024).

C. Provide resumes for staff to be responsible for performance of:

1. Account management

2. Financial reconciliation

3. IT support

4. Clinical pharmacy support

5. Senior executive overseeing account

D. Complete the following form regarding contracted or rebranded services (if not applicable, indicate "this service provided internally" on the description line).

1. Claims Adjudication

Description_________________________________________________________

Contracted Provider__________________________________________________ Date Service Commenced_____________________________________________

2. Pharmacy Network Administration (Contracting, Payment, etc.)

Description_____________________________________________________

Contracted Provider__________________________________________________ Date Service Commenced_____________________________________________

3. Formulary Design, Content, and Composition

Description_____________________________________________________

Contracted Provider__________________________________________________ Date Service Commenced_____________________________________________

4. Formulary Rebate Administration

Description_____________________________________________________

Contracted Provider__________________________________________________ Date Service Commenced_____________________________________________

5. Mail Service Pharmacy

Description________________________________________________________

Contracted Provider__________________________________________________

E. Can all service guarantees and performance agreements outlined in this RFP (and the subsequent contract) be applied to subcontractors? If not, please explain.

F. For all subcontractors mentioned above, outline payment methods and assurance that service will remain continuous throughout the contracted period.

G. For all subcontractors mentioned above, provide insurance documentation for services provided via primary vendor.

H. Outline methods of assuring insurance requirements are met and maintained by subcontractor on an ongoing basis.

I. If a rebate aggregator is utilized (as opposed to authoring and executing your own rebate contracts), outline how payment can be assured, even when the aggregator disputes claim eligibility. Contract language, which states that rebates can only be paid based on remittance by the aggregator will be considered much less desirable than arrangements were where objective $/Rx guarantees are applied.

J. Indicate the number of any outstanding legal actions pending or lawsuits yielding court decision or settled in the past two years against or involving your organization, if any. Explain the nature and current status of the action(s). Can you ensure these actions will not disrupt business operations?

SECTION III

IMPLEMENTATION PLAN

A. Provide a proposed implementation plan and timetable, beginning with the award of business to the effective date of coverage (October 1, 2026, planned effective date), including:

· Steps required for implementing the program.

· Roles played by the Client/Respondent.

· Loading eligibility data file.

· Production and distribution of network directories and enrollment materials.

· Contacts and personnel assigned to each step of the implementation process.

B. What is the minimum amount of time recommended to ensure an accurate and eventless transition into the proposed program?

C. Is your organization willing to state (in final contract) that they are carrying out services in a fiduciary manner for members of the company's health plan? If not an unqualified “yes,” explain.

D. Describe your ability to reprocess historical claims within your claims adjudication system prior to implementation for testing and validation purposes. Will you provide this service at no extra charge?

E. Are there any start-up fees with implementation? If so, how much are these fees and what do they provide? Is there an additional fee for receipt and programming of custom eligibility files? Is there an additional fee for receipt and programming of claim, prior authorization or open refill transfer files? If so, please provide an estimate.

F. Provide applicable performance guarantees in Appendix C.

G. Describe the member’s experience related to the mail order open refill transfer (ORT) file onboarding process. How does the first script get filled? Do you (or your mail order vendor) proactively reach out to members during transition? If so, when? Are transferred scripts available to the member on the web site upon initial web site setup and log in?

SECTION IV

ADMINISTRATIVE FEES

Complete the following in accordance with the instructions provided. Additionally, please provide administrative fees in Appendix B.

Plan Effective Date: October 1, 2026 Basic (per claim) Fee:

Per Employee Per Month (Alternate) Fee:

Services Included:

· Production of ID cards for all existing members initially, to new members monthly, including medical claims information.

· Providing on-line access to formulary lists and provider directories to all existing members with web access and printed formulary guides as needed

· Claims Adjudication

· Standard Systems Edits

· Basic Formulary Management

· Eligibility Verification and Maintenance

· MAC Program Administration

· Standard Data Reporting and Online Access for Client

· Customer Service including toll-free telephone access

· Provider Management and Education

· Prior Authorization, step therapy, and quantity edits

· Appeals

· DUR, both Prospective and Concurrent

· Medication Management

All the above services should be covered under the fee stated above. However, some services may be offered as optional or ancillary and be covered by separate add-on fees

A. Outline all additional fees (beyond the administration fee) that will be added to the client’s billing. State whether these additional fees are optional or integrated into the standard offering of your PBM services. It is very important to represent the actual anticipated administrative fee.

B. Outline all additional sources of revenue to the PBM.

C. Detail all additional fees/charges not covered under basic fees (postage, printings, booklets, start up costs, etc.). Be sure to list all charges. We will utilize these fees quoted for inclusion in the contract executed. Variation from stated fees may eliminate the candidate Respondent.

D. The fees presented in this information are binding during the life of this contract. Any unsolicited changes to these fees or additional fees may be grounds for termination. Does the Respondent comply with these conditions?

E. Are reversals subject to an administrative fee?

F. If a claim is reversed, is the administrative fee for that claim reversed?

G. List any other related services that the Respondent offers that have not been specifically requested in this RFP. Provide charges and fees for these services.

H. Detail any administrative fee offsets or credits associated with your entity/parent entity administering the medical benefit.

· PBM’s routinely sell detailed drug utilization data to outside firms, including database managers, marketing firms, drug manufacturers and others. Such sales will be prohibited under the contract between the successful Respondent and the Client, unless a specific agreement is made that detail:

· Data content (i.e., Patient, Prescriber, Pharmacy);

· The customers to which the data will be sold;

· Time frame and scope;

· Compliance with Federal HIPAA Privacy and Security Rules

This restriction will not preclude the successful Respondent from including utilization information in statistical summaries, but use of specific data will be prohibited.

The Respondent acknowledges the above and will accept penalty language stipulating as such in the final executed contract.

Certification - My signature below certifies that I am an officer of the company and authorized to bind it in accordance with the above fee quotation and compliance with the above statements.

Submitted by: _______________________________________

Signature Date_______________________________________

Printed Name, Title ___________________________________

SECTION V

CLAIM PROCESSING SERVICE

General Claims Processing

A. Indicate the claim processing operation and facility that will be utilized in the management of this account. Is this system owned and operated by your organization?

If not, name the company you are proposing to use.

What is the relationship between your organization and this company?

How are the necessary quality and time requirements for claims processing assured for this subcontractor? (Outline separately for claim systems, billing systems, and reporting systems)

B. What are the normal hours of operation of the claim operation, customer service, and mail-order facility? Include extended or weekend shifts. What mechanisms can enrollees utilize for emergency requests that fall outside of the normal hours of operation?

C. What national drug database will be utilized for claims processing? What is your position and strategy for potential changes in the national drug databases?

D. What is the average turn-around time for reimbursement of network pharmacies claims?

E. Do you provide full, detailed accounting of each claim on your claims reconciliation file (CRF)? How frequently is it provided? Can the format be customized?

Retail Claims Processing

A. For the claim office proposed, provide the following for the last two calendar years: (a) Financial accuracy as a percentage of total claims dollars paid (include over- and underpayments) and (b) Coding accuracy as a percent of total claims submitted.

B. How do you avoid duplicate payments of the same claim? If duplicate payments or overpayments are discovered, what are your procedures for recovery of the overpayments or duplicate payments?

Mail-Order Claims Processing

A. How many days advance notice must an enrollee provide to guarantee that their supply is received before the existing supply is depleted?

E. What is the average time in days between receipt of claim and delivery to enrollee (include delivery time)? Are you able to provide a service guarantee?

F. Are shipping costs included in the dispensing fee? If not, define the additional cost (include rush order cost, if applicable).

G. The retail MAC pricing schedule will be applied to all mail and specialty service generic prescriptions. Indicate your approval of this to be included as a contract statement.

H. If specific performance standards are not met (solely determined by client’s metrics), may the client select a mail service vendor independent from their PBM relationship?

I. Is the mail service pharmacy (internal or contracted) IIAS certified (100% certified for FSA card transactions)?

SECTION VI

ACCOUNT SERVICE

A. Discuss how GCPS will be billed for retail network, mail-order, and administrative fees. Will you bill separately for administrative service fees?

B. What sales office would handle the general servicing of this account? What are the standard office hours for the sales and service offices?

C. Will dedicated account service representatives be assigned to this account?

D. Do account service representatives have on-line access to real-time claim processing information? Do these representatives have authority to approve and/or override claims?

SECTION VII

MEMBER SERVICES

A. Provide audited telephone response data for the past two years. Include time to answer, talk-time, and abandonment rate. Are telephone performance reports available online? Provide applicable guarantees in Appendix C.

B. Provide methods for member support services for selecting and/or locating network pharmacies.

C. Describe the member grievance protocols in place.

D. What is the average response time for general questions? How is this logged and monitored through an automated system? Provide applicable guarantees in Appendix C.

E. For the following two questions, please provide as much detail as possible, including screenshots, examples, etc. Provide details of service, function, value to GCPS

a. What services are available to members via the Internet to review and manage their prescription benefit? How is this service accessed?

b. What mobile application services are available to members to review and manage their prescription benefit? How is this service accessed?

F. Describe the process for members to gain online access to manage their home delivery (mail-order) prescriptions, such as refills, renewals, check order status and history, update shipping and payment information, and set notifications.

SECTION VIII

PHARMACY NETWORK

A. What number and percent of available retail pharmacies (nationally) are in your network?

B. Outline, with zip code, all pharmacies in Virginia that are not contracted for your network.

C. If it is found that a pharmacy currently non-network for your system is essential to the client, please outline the method of enrolling the pharmacy to your network.

SECTION IX

PHARMACY NETWORK MANAGEMENT AND QUALITY ASSESSMENT

A. Describe your organization’s objectives/efforts regarding pharmacy relations. Is there an oversight committee that addresses pharmacy relations issues?

B. What are your criteria for auditing network pharmacies? Describe in detail the claims auditing procedures established by your company (frequency, extent, etc.).

C. What percent of erroneous or fraudulent payments to pharmacies are discovered through your audit efforts? Do you return 100% of all monies you recover based on the incurred claim experience? If not, explain what portion (if any) is returned.

SECTION X

PRESCRIPTION DRUG REIMBURSEMENT

A. In Appendix B, provide the brand drug reimbursement formula guaranteed for all plan members in all locations (mail and retail). Provide this as a % discount off post-settlement AWPs.

B. Successful vendor will pay GCPS a fine equivalent to 20% of any plan paid cost excess due to inaccurate setup of pricing at implementation or subsequent inaccurate pricing due to changes made by the vendor. Provide confirmation of your agreement with this stipulation.

C. Outline your reimbursement method. Specifically, what is the basis (including formula(s)) of determining prices for brand drugs?

D. Submit your proposed generic pricing in an Excel spreadsheet named “Guaranteed Fixed Unit Cost Pricing”. The values for the generic pricing must be the maximum $/unit ingredient cost that the client will be charged for a given billing cycle, excluding U&C claims. This will be part of the final contract. Include pricing for all generic medications. The final, contractual MAC shall include all generic medications within the drug database to which you subscribe. This pricing must be submitted based upon GPI or GCN.

a. Confirm U&C claims will be excluded from the generic fixed unit cost guarantee calculation.

E. What is your average discount from AWP (retail and mail) for brand medications? What is the overall brand discount from AWP that can be guaranteed (with financial penalty)? Are there requirements/exclusions associated with this guarantee (be specific)? No exclusions other than those listed here will be allowed in the contract.

F. What is your source for AWP? What is the name of the database used for MAC? How often are prices updated?

G. Will you guarantee that the average cost per brand drugs achieve no less than the percentage discounts from AWP? (cumulative AWP discount < guaranteed AWP discount).

H. It is required that your organization fully support and promote “$4” prescription programs (“Wal-Mart” programs). List the pharmacies in your networks that have a $4 charge for many generic drugs. Outline the programs you have implemented that have advocated and increased use of these “$4” programs.

I. Quantify the value of the lesser of provision in terms of percentage of savings above and beyond the contractual discount percentage.

J. With respect to all pricing formulas presented, will you agree to permit an audit of your claim files by GCPS representatives to verify the reimbursement prices established in the contract?

K. Upon completion of vendor contract, a statement guaranteeing that the average price for a generic (drug/strength/form) will not exceed the agreed upon MAC list (barring exceptional circumstances) will be required and included in the final executed contract. Is this acceptable in your vendor contract?

L. The guaranteed generic unit cost (MAC) list must apply at the point of sale. Proposals with other pricing models containing a reconciliation to the guaranteed generic unit cost list at a later date may result in the proposal not being considered. Please confirm your proposal applies to the guaranteed generic unit cost list at the point of sale.

M. What are your means of assuring reasonableness for compounded drug charges? Outline pricing policy and methods of assuring accurate pricing. Describe clinical criteria utilized to ensure high-cost compounds with commercially available alternatives are denied. Is evidence of efficacy required prior to approving a high-cost compound claim?

N. Are all dispensing fees reported and billed to the client the same as that adjudicated for the pharmacy at the point of sale?

O. Outline all dispensing fees, stated as maximum $/Rx that will be billed for any given month (retail/mail, brand/generic).

P. There will be no minimum charges to the client or their members for any claim (retail, mail or specialty). The client and member will be billed based upon the actual cost of the claim. Confirm your agreement with this statement.

Q. What is your policy on reclassifying brand or specialty drugs, which may lead to lower rebate credits?

R. Brand and generic definitions must be stated in the contract as follows. Please confirm your agreement to define these items as such.

a. Brand: Brand shall refer to medications designated as “M”, “N”, or “O” in Medi-Span.

b. Generic: Grand shall refer to medications designated as “Y” in Medi-Span.

S. Please list, in detail, all multi-source brands which are adjudicated as preferential against a generic version. One common example is Advair.

a. For each of the medications mentioned in item T, outline to what extent the multi-source brand is preferred…formulary copay, exclusion of generic, etc.

b. Which drugs are excluded due to inclusion of each multi-source brand?

c. For each of the medications mentioned in item T, please provide, in detail, the logic for this designation.

SECTION XI

GENERIC DRUG MAXIMUM ALLOWABLE CHARGE (MAC) PROGRAM

For the purposes of this section, “MAC” refers to the guaranteed fixed unit cost pricing for generics referenced in item I below.

A. Provide a general description of your generic drug maximum allowable charge (MAC) program.

B. How does your MAC program require utilization of a generic by the dispensing pharmacy?

C. Based on your latest data available, what is the effective discount from AWP of your MAC prices? Describe this generic pricing in terms of WAC.

D. Provide the number of generic products for which you have a MAC price. What percentage of all generics dispensed does this represent?

E. Does your MAC price apply to EVERY pharmacy in your network, without exception? If not, explain in detail. If this MAC does not apply to all pharmacies, what is the rate to pharmacies that are not applicable to this generic MAC listing.

F. Do client’s members always pay the MAC price for applicable generics regardless of the pharmacies' contract (with consideration of “lesser of” logic)?

G. Does your network contract (or with a subcontractor) stipulate that participants always pay the lesser of U&C or the MAC based ingredient cost of the generic Rx plus dispensing fee?

H. Provide the complete generic MAC list in Excel format (including unit price) a file named “Guaranteed Fixed Unit Cost Pricing”. As this will be a requirement of future service, failure to provide such greatly reduces the possibility of being awarded this business. This MAC list must include all generic medications in the drug database to which you subscribe. If a multi-source generic is utilized and you do not submit a price, it will be disadvantageous to your bid. This MAC will be applicable to the business engaged for this client via this RFP and will be incorporated into the final contract. Indicate your acceptance that this MAC will be incorporated and part of the contractual obligations of your service. This pricing must be submitted based upon GPI or GCN. Do not submit pricing at a greater level of detail than GPI or GCN (e.g., package size).

I. The generic MAC list must be equally applicable to mail service claims and specialty pharmacy distribution as well as retail. Indicate your acceptance of this stipulation in the final PBM/client contract.

F. Cost per unit, in excess of the guaranteed MAC generic pricing ($/unit, included in the contract) will be reconciled and paid to the client every month. Most desirable is that all generic claims will be adjudicated (paid) at exactly the amount on the guaranteed pricing schedule. U&C claims are not counted towards meeting the MAC pricing guarantee. Acknowledge acceptance of these terms and inclusion in any future contract

G. Describe the methods and timing by which the MAC list will be improved (for existing generic products) and/or enhanced to include newly available generic products.

SECTION XII

REPORTING/DATA FEEDS

A. What is your standard reporting cycle for client cost and utilization analysis?

B. Are customized reports available at the request of GCPS at no cost?

C. Do you provide clients with a comparison of financial data to your book of business?

D. Do you provide clients with a comparison of financial data to similar clients?

E. Provide a sample report containing the following:

1) Paid Claims Summary (Total membership, number of utilizing members, net claims --including breakdown of claims per eligible member, brands, generics, brand with generic, mail order, percent of mail order – ingredient cost, dispensing fees, taxes, total member co-pays, total paid by other plans, total plan cost, and other data as needed)

1. Monthly

1. Excel file preferred

2) Top Drug Report (detail of cost and utilization by top drug products, including common usage)

1. Quarterly

1. Excel file

3) High amount claimant report (including enrollee name, unique enrollee ID number, number of RX filled, cost, names of drugs).

· Quarterly

· Excel file

4) Formulary Savings and Rebate report (provide sample).

1. Quarterly

1. Excel file

5) Claims paid by therapeutic category showing total number of claims, eligible charges and claim payments for each category.

1. Quarterly

1. Excel file

F. GCPS will be provided a full data file, without any elements deleted, monthly, and for three months subsequent to the termination of the contract. Indicate your consent to including the above statement in the final contract. Note that this requirement is not related to termination files. It is intended to ensure detailed claim data will be sent to USI and/or the client at no charge from implementation through all runout post-termination.

SECTION XIII

FORMULARY PROCEDURE

A. Confirm all generic medications will be included on tier 1 unless otherwise directed by the client. If this is not confirmed, provide a list of all generics (with GPI included) that will not process at tier 1.

B. What is the composition of your formulary committee? How are members of the P&T Committee compensated?

· Salary (if employees)

· Company stock

· Consulting fees

· Expenses

· Honorarium per meeting.

C. Are there requirements for disclosure of all manufacturer relations/payments for all members of the formulary committee (including employees)?

D. Is formulary rebate contracting an element of the presentation of value assessment for drugs or for therapeutic class?

E. Do you consider your formulary "evidence-based?"

F. If the answer to "E" above is yes, provide, in detail, your method of critical evaluation of research, your method of compilation of studies, and your method of applying statistical analysis in determining whether a medication has value vs. another agent.

G. Are any legend drugs excluded from your formulary resulting in them not being covered? If so, list drugs and rationale. Can the client elect to include coverage? Can existing utilizers be grandfathered?

H. Grandfathering is essential for our clients. Describe the extent of grandfathering (including perpetual copay override) options available to the client when faced with members that are on medications that are now tier 3. Are there any limits to your ability to perform this grandfathering? If so, describe. Also, confirm grandfathered claims will not be excluded from rebate guarantees. Items to potentially be grandfathered include:

SECTION XIV

FORMULARY REBATES

A. Will you disclose specific discounts by manufacturer, by drug upon signing the PBM/client contract?

B. Do your contracts with manufacturers allow for full disclosure of discounts and terms to auditors selected by GCPS?

C. If GCPS requests a rebate guarantee, can your organization provide a rebate guarantee (rebate $ as a % of total ingredient cost)?

D. Are there brand drugs on your formulary for which no rebates are given but are included because they are clinically superior to other options? If so, outline.

E. On what percentage of drugs in your formulary are rebates paid?

F. On what percentage of brand-name drugs in your formulary are rebates paid?

G. How will you provide GCPS with information that verifies rebate monies have been accurately credited by:

· Reporting by manufacturer

· Reporting by product line

· Reporting by NDC (required)

· Net Therapeutic Cost

H. If GCPS were to begin with you on October 1, 2026, in which month of the same year would the first rebate check be received? Guaranteed rebates payments must be paid within 60 days of the close of a calendar quarter.

I. The successful Respondent must disclose fully its economic relationships with all drug manufacturers to GCPS. This will include all such revenue sources, both direct and indirect, including but not limited to drug spend rebates and manufacturer administrative fees. Acknowledge that this is acceptable.

J. Will you accept a penalty fee for noncompliance with the above (Q)?

K. What is the guaranteed yield for rebates in terms of $/brand RXs and % of $ ingredient cost?

· Are there requirements/exclusions associated with this guarantee (be specific)? No exclusions other than those listed here will be allowed in the contract. Note that diabetic supplies must be included in the rebate guarantees.

· In Appendix B, please complete the table with rebate guarantee as a per brand Rx, separately for retail, mail, and specialty drug.

· Discuss methods for renegotiation of rebate guarantees in the event rebate yields increase over time. Contract language will include a statement that rebate guarantees can be renegotiated annually.

L. Please complete the following table with exclusion status for common rebate guarantee exclusions. If additional exclusions are required in your contract, please add them to the table and indicate they are an exclusion. Only those items listed as excluded here will be allowed in the final contract with the client. This list is included for your reference.

Multi-Source Brands

Tier 3 Brands

Excluded Drugs

Limited Distribution Drugs

340B Claims

Over-The-Counter Drugs

Diabetic Supplies

OTC Insulin

Member Cost Share > 50% (after deductible)

Vaccines

Non-FDA Approved Drugs

Re-Packaged NDCs

Compound Drugs

Discount Card Program Claims

Claims Eligible for Federal Supply Schedule (e.g., Department of Veterans Affairs, U.S. Public Health Service, Department of Defense, Indian Health Services

COB Claims

Cosmetics

M. Delineate all specialty medications that will not receive a rebate, if any.

N. Confirm that the specialty rebate will be paid on all specialty drugs, regardless of the pharmacy at which they were filled (retail, mail, specialty).

O. Rebate guarantees are not to include any yield from coupon enhancement programs. If such is to be included in rebate guarantees, please provide separate rebate guarantees, one with and one without coupon yield included. Please acknowledge your agreement that a single rebate guarantee provided by your entity does not include yield from coupon enhancement programs.

P. Describe your method to assure retail pharmacy initiated 340B assertions do not reduce rebates to the client when the client has not requested nor allowed 340B utilization. How do you keep pharmacies from claiming 340B when the plan sponsor is not part of the 340B process?

· Describe how 340B claims will not dilute your rebate offer.

· Describe how the client benefits from a claim classified as 340B.

· Does the client get charged the 340B price for all 340B claims?

· Confirm there will be no claims excluded from rebates under a 340B category unless the plan sponsor paid the 340B pricing.

Q. Are any rebates received by you from manufacturers for generic specialty medications?

R. How do you maximize client value and rebates without forcing the plan to return rebate funds to the PBM in instances where rebate credit language is in play?

SECTION XV

CLINICAL PROGRAMS

A. Do you provide emergency access to a registered pharmacist 24 hours a day?

B. Do you have a 24 hour service to respond to member’s benefit or therapeutic questions?

C. Do you provide free educational information to members with (describe)

· Allergy

· Asthma

· Cardiovascular

· Congestive Heart Failure

· Depression

· Diabetes

· Hypertension

· Pain Management

· Smoking Cessation.

D. Do you provide free educational information to members about:

· Adverse Drug Events

· Medication Safety and Storage

· Poison Control

· Child Safety

E. Do your registered pharmacists consult directly with prescribing physicians?

F. Can you assure GCPS that their prescription claim data will not be distributed or sold to any outside party in any fashion, under financial penalty?

G. Describe your physician and member education efforts to maximize use of generic diabetic medications and minimize brand diabetic drug use.

H. Describe in detail your method for excluding non-FDA approved and unique compounded products (e.g., Lidovex, Pennsaid).

I. The following language will be included in the contract. Confirm your agreement with this language. “No utilization management (exclusions, step therapy, prior authorization, quantity edits, age edits, gender edits, etc.) will be made without at least six months’ notice and prior approval of the client.”

J. Describe your method of limiting or excluding from adjudication superfluous, expensive medications which have a brand product designation in databases such as steroid patches, topical NSAIDs, and combinations of generic products.

K. Describe any mandatory program (s) that a client must utilize in the process of engaging your services. Describe the impact if the client refuses to utilize these services.

L. What innovative strategies to assure maximum value from GLP-1 use do you provide? Are there any associated fees? What programs/edits are required when allowing use of GLP-1 drugs?

SECTION XVI

SPECIALTY DRUG PRICING AND MANAGEMENT

A. Does your organization own or subcontract specialty pharmacy services?

B. Is GCPS under obligation to use your organization’s specialty pharmacy services?

C. Describe any innovative means that your organization utilizes to minimize the cost of specialty drugs for clients and their members.

D. Do any of the rebate contracts utilized by your company (or contracted rebate vendor) limit the extent and ability of your organization to prior authorize and/or deny utilization of a medication when it is deemed not meeting criteria?

E. Specialty pricing must be provided and guaranteed at the drug level. AWP discount pricing and guarantees at the aggregate level are not allowed. Please confirm. Submit your proposed specialty list and associated pricing, at the GPI level, as “Appendix E – Specialty Pricing” with your RFP response.

a. How are new specialty medications priced and added to the guaranteed drug list?

b. Due to significant annual AWP inflation for specialty medications, the client must be protected from significant financial harm. Describe methods this can be accomplished, including increases in AWP discounts to coincide with price increases.

c. All oral/multi-source generic specialty medications must be included on the guaranteed MAC generic pricing list and must be adjudicated at that pricing.

F. Describe, in detail, your process for the addition of biosimilar products to your formulary when they come to market.

a. If a biosimilar product is added to the formulary will the related brand drug continue to be available on the formulary? Is the time the brand drug remains covered on the formulary limited?

b. Will biosimilar products be included in specialty rebate guarantees?

c. Provide a table with line item (gross cost, rebate, net cost) information on the Humira biosimilar products vs. brand Humira. How was this data utilized to select Humira class products for the formulary?

d. Describe how Hyrimoz is covered relative to Humira.

G. What programs do you offer to properly assign the value of manufacturer coupons to member accumulators?

H. Please describe your program for maximizing the value of patient-assistance coupons for

a. The patient

b. The plan sponsor

c. Avoiding having member coupon apply to deductible

I. Are prescriptions which are impacted by coupon maximization programs fully eligible for formulary rebates and qualify as such?

J. A common complaint of PBM-owned specialty pharmacies is that they do not perform effective clinical management due to their financial interest through distribution. Outline in a single page the reaction and rebuttal (with line-item specificity) to this concern.

K. The following criteria must be met related to specialty rebates.

a. There may be no requirement of 90-day supply in order to obtain rebate payments.

b. Specialty rebates must be paid on all specialty claims, regardless of the pharmacy (retail, mail, specialty) at which the claim was filled.

L. Describe, in detail, the activities (clinical and otherwise) your organization utilizes and apply to reduce the client’s exposure to specialty drug cost.

a. Provide the title and details of five programs/activities and savings guarantees associated with each. Include financial penalties to be paid to the client if savings guarantees are not met.

b. In as promotional (but factual) manner as desired, describe in detail why the programs offered by your organization are the most effective and superior specialty risk management programs in the marketplace.

M. Any modifications in what is defined as specialty must be reviewed and approved by USIRx prior to the change taking place, such approval to not be withheld without cause.

Appendix A - Client Relations

1. Clients Form: Complete the following chart, listing 5 clients/groups.

of Enrollees Initial Offer Date

Contact Name

Address

Telephone Number

2. Terminated Contracts Form: Complete the chart below of groups that have terminated their contracts with your plan since December 31, 2024.

of Enrollees Initial Offer Date

Contact Name

Address

Telephone Number

3. Complaints/legal action Outline, in detail, any past or pending legal actions/complaints from current or former clients (include all legal actions, court settled or otherwise, since 2020).

Appendix B – Financial Summary

Please refer to the Price Proposal - Medical and Re-insurance Pricing Workbook.

Appendix C – Performance Guarantees

Instructions to Respondents: Provide performance guarantees and financial penalties specific to this client. Performance guarantees may be provided below or in a separate document named “Appendix C – Performance Guarantees”. At a minimum, guarantees for the following must be included:

1) Implementation tasks, including time frames, benefit coding accuracy, web site setup and client satisfaction

2) Standard customer service call center metrics, including time to answer, talk-time, abandonment rate and first call resolution

3) Retail pharmacy dispensing accuracy

4) Mail pharmacy, including dispensing accuracy and turnaround time for clean scripts and scripts requiring intervention

5) Specialty pharmacy, including dispensing accuracy and turnaround time for clean scripts and scripts requiring intervention

6) Claim processing system, including availability and recovery time

7) Reporting, including standard reporting and plan setup recommendations/annual review

8) Client satisfaction surveys related to customer service/account management

9) Member satisfaction surveys

10) Account management response time for standard and critical items

11) Post-implementation tasks, including eligibility load timing and benefit coding accuracy

A. What is the frequency and timing of performance guarantee reporting and reconciliation?

B. What is the timing of payment for any amounts due to the client?

C. What is the total amount that will be placed at risk for the client?

D. All guarantees, including those in Appendix B, must stand on their own and must be effective as of the implementation date, regardless of contract execution status. No offsetting of guarantees with results from other guarantees is permitted. Confirm your acceptance of this requirement.

Appendix D – Summary of Key Issues

1. All claims will be billed to GCPS in the exact amount that is paid to the pharmacy at the point of sale. _____ Yes _____ No

Short explanation of “No”_______________________________________

2. Our company (PBM) is guaranteeing that the maximum cost per unit for any given generic drug will be the value submitted on the MAC list (Section XI, Item I). This value will apply to all generic claims for all retail, mail and specialty pharmacies (enforced by specific, guaranteed contractual language). U&C claims and unique programs, such as, but not limited to “Wal-Mart $4 programs,” will not be considered in determining adherence to the guarantee.

_____ Yes _____ No

Short explanation of “No”_______________________________________

3. What types of claims are you proposing for exclusion from the brand AWP discount? What types of claims are you proposing for exclusion from the rebate guarantee? Confirm the list of rebate exclusions in this response is the same as your response in Section XIV, items K and L.

4. GCPS is allowed to independently contract, directly, with its own specialty pharmacy vendor. _____ Yes _____ No

Short explanation of “No”_______________________________________

5. PBM agrees to provide all testing as described in Section III, item J.

_______Yes _______No

Short explanation of “No”_______________________________________

6. Grandfathering is essential for our client. Acknowledge grandfathering will be supported for all aspects of the benefit (formulary copay tier overrides, prior authorization, step edits, quantity limits, age edits, gender edits, exclusions), as described in Section XIII, item H. Note that the inability to permanently grandfather all disruption or exclusion of grandfathered claims from rebate guarantees will significantly reduce the value of your offer. Also, confirm grandfathered claims will not be excluded from rebate guarantees.

_______Yes _______No

Short explanation of “No”_______________________________________

7. Upon termination of the relationship with the client, all necessary data will be provided to the new PBM free of charge. This includes 12 months of historical claim data with sufficient information to successfully make the transfer (including member information, copay and formulary indicator), associated accumulator information (if applicable), prior authorization file with all PAs active after the implementation date, mail order ORT, and specialty ORT. Each file shall be provided three times; once for testing purposes early in the implementation process, once for production data and once for lag data post-implementation.

_______Yes _______No

Short explanation of “No”_______________________________________

8. Confirm PBM agrees to meet with USI Pharmacy Consulting annually to negotiate additional improvements in the generic unit cost list.

_______Yes _______No

Short explanation of “No”_______________________________________

9. PBM will provide a full data file, without any elements deleted, monthly, and for three months subsequent to the termination of the contract. This file must include AWP. Note that this requirement is not related to termination files. It is intended to ensure detailed claim data will be sent to USI and/or the client at no charge from implementation through all runout post-termination.

_______Yes _______No

Short explanation of “No”_______________________________________

10. Confirm PBM agrees that rebate guarantees can be renegotiated annually.

_______Yes _______No

Short explanation of “No”_______________________________________

11. Specialty brand pricing is guaranteed at the drug level.

_______Yes _______No

Short explanation of “No”_______________________________________

12. Unless otherwise indicated by plan documents, OTC products (excluding diabetic supplies) and combinations of only OTC products will not be adjudicated. This includes combinations of OTC products that have obtained a legend status.

_______Yes _______No

Short explanation of “No”_______________________________________

13. All generic $/unit pricing will apply to all distribution channels, including specialty pharmacy.

_______Yes _______No

Short explanation of “No”_______________________________________

14. All guarantees, including those in Appendix B and Appendix C, must be effective as of the implementation date, regardless of contract execution status.

_______Yes _______No

Short explanation of “No”_______________________________________

Certified as accurate ______________________________

Title___________________________________________

Dated___________________________

CONFIDENTIAL AND PROPRIETARY: This document and the information contained herein is confidential and proprietary information of USI Insurance Services National, Inc. ("USI"). Recipient agrees not to copy, reproduce or distribute this document, in whole or in part, without the prior written consent of USI. Estimates are illustrative given data limitation, may not be cumulative and are subject to change based on carrier underwriting.

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