Exhibit J - Scope of Work (SOW).pdf

RFP No. HHS0017240 Exhibit J

Pharmacy Benefits Management Services for Texas HIV Medications Program (THMP):

State Pharmacy Assistance Program (SPAP), Texas Insurance Assistance Program (TIAP), and

Texas Insurance Assistance Program-PLUS (TIAP-PLUS)

RFP No. HHS0017240

Exhibit J, Scope of Work (SOW)

RFP No. HHS0017240 Exhibit J

Table of Contents

SCOPE OF WORK

1.1 DESCRIPTION OF SERVICES

1.1.1 Coordination of Payment Services

1.1.2 Coordination of Benefits Services

1.1.3 Administrative Requirements

1.2 TRAINING

1.3 REPORTING

1.4 DELIVERABLES

1.5 KEY PERFORMANCE MEASURES

1.6 REMEDIES

1.7 INVOICE AND PAYMENT

1.8 OPERATIONAL PLAN

1.9 TRANSITION PLAN

1.10 TURNOVER PLAN

1.11 ACCEPTANCE CRITERIA

1.12 TEXAS RISK AND AUTHORIZATION MANAGEMENT PROGRAM

RFP No. HHS0017240 Exhibit J

SCOPE OF WORK

1.1 DESCRIPTION OF SERVICES

For the purposes of this SOW, THMP is used to refer to its insurance assistance programs: SPAP, TIAP, and TIAP-PLUS combined. Contractor shall serve as the Pharmacy Benefits Manager to provide cost-sharing assistance to eligible participants of the THMP insurance assistance programs. These participants will be determined to be eligible for assistance by DSHS.

1.1.1 Coordination of Payment Services

Contractor shall provide the following administrative services:

a. Coordinate the payment of deductibles, co-payments, and coinsurance for medications for participants enrolled in a THMP insurance assistance program.

b. Coordinate the payment of insurance premiums to multiple insurance companies for participants enrolled in a THMP insurance assistance program who DSHS approves for insurance premium assistance.

c. Provide claims level data that differentiates claims paid between the various insurance benefit levels and insurance assistance programs within the THMP.

d. Enact internal controls that ensure that the THMP does not pay for a medication(s) that is not approved by the THMP and is not in the formulary for the specific insurance plan in which a participant is enrolled.

e. Develop and maintain a statewide network of participating pharmacies that supports coordination of benefits with third-party payers including at least one mail order pharmacy option and sufficient geographic coverage to serve rural and urban areas.

f. Ensure that pharmacies in the network of pharmacies do not use 340B stock or file pharmaceutical rebates for medications purchased under THMP.

g. Provide DSHS staff with electronic access to view claims adjudication and participant enrollment. Contractor must ensure its system is accessible between the hours of 8:00 a.m.- 7:00 p.m., Central Standard Time, Monday through Friday.

h. Maintain a help desk that will provide assistance to pharmacies, THMP participants, THMP staff, and health insurance companies with billing and claims issues. At minimum, the help desk must be available between the hours of 8:00 a.m.-7:00 p.m., Central Standard Time, Monday through Friday. Contractor shall provide staff that are bilingual in English/Spanish.

i. Collect and manage claims level data on each payment made on behalf of a THMP enrollee.

This data shall be provided by the Contractor to DSHS in a format specified by DSHS

RFP No. HHS0017240 Exhibit J within 48 hours of request. This includes ensuring that all credits and adjustments for overpayments maintain full traceability to the original transaction and are applied back to the individual client and original date of service. This may include, but is not limited to, submission as a secure flat file such as CSV or Excel via secure file transfer or system portal and inclusion of standardized data fields such as participant identifier date of service, National Drug Code, amount paid, funding source, program type, pharmacy identifier, and claim status.

j. Maintain a process capable of implementing and monitoring cost containment measures (such as annual expenditure caps on participant services, and participant or medication prior authorizations).

k. Ensure the primary payor status of any insurance company is not changed. The THMP will always be considered a secondary payor.

l. Provide THMP with claims level data, which includes a distinction between Public Health Service (PHS) and non-Public Health Service covered entities per 340B Office of Pharmacy Affairs Drug Pricing Program guidelines. (https://www.hrsa.gov/opa)

m. Comply with the National Council of Prescription Drug Program’s (NCPDP) standards for pharmacy drug claims and coordination of benefits (located at https://www.ncpdp.org/).

n. Comply with all applicable federal and state regulations and statutes, as may be amended, including but not limited to:

1. Texas Health and Safety Code, Chapter 81:

https://statutes.capitol.texas.gov/?tab=1&code=HS&chapter=HS.81&artSec=.

2. Texas Health and Safety Code, Chapter 85:

https://statutes.capitol.texas.gov/?tab=1&code=HS&chapter=HS.85&artSec=85.271.

3. U.S.C.A, Title 42, (The Public Health and Welfare, Chapter 6A:

https://uscode.house.gov/us/usc/119-121/t42.

o. Comply with all applicable state and federal policies, standards and guidelines, as may be amended, including, but not limited to:

1. Centers for Medicare and Medicaid Services data sharing guidelines:

https://www.cms.gov/medicare/coordination-benefits-recovery/employer-services/voluntary-data-sharing-agreement.

2. Health Insurance Portability and Accountability Act (NCPDP) Regulations and Standards; Public Health Law 104-191; Health Insurance Portability and Accountability Act of 1996:

https://aspe.hhs.gov/reports/health-insurance-portability-accountability-act- 1996.

https://www.hrsa.gov/opa https://www.ncpdp.org/ https://statutes.capitol.texas.gov/?tab=1&code=HS&chapter=HS.81&artSec= https://statutes.capitol.texas.gov/?tab=1&code=HS&chapter=HS.85&artSec=85.271 https://uscode.house.gov/us/usc/119-121/t42/frontmatter/ https://www.cms.gov/medicare/coordination-benefits-recovery/employer-services/voluntary-data-sharing-agreement https://www.cms.gov/medicare/coordination-benefits-recovery/employer-services/voluntary-data-sharing-agreement https://aspe.hhs.gov/reports/health-insurance-portability-accountability-act-1996 https://aspe.hhs.gov/reports/health-insurance-portability-accountability-act-1996

RFP No. HHS0017240 Exhibit J

3. National standards to protect the privacy of electronic health information:

https://www.hhs.gov/hipaa/for-professionals/privacy/index.html.

4. National security standards for the security of electronic health care information: https://www.hhs.gov/hipaa/for-professionals/security/index.html.

p. Provide and maintain access to all current laws, standards and guidelines applicable to the Contract, along with any other applicable Contract documents, to its employees’ performing services under the Contract.

q. Fully cooperate with all programmatic performance monitoring activities conducted by or on behalf of DSHS, including activities related to program operations, reporting, compliance, and service delivery. Such activities may include data requests, participation in meetings, audits, and implementation of corrective actions as directed by DSHS.

r. Receive prior written approval from DSHS before deviating from any applicable policies, procedures, and protocols relevant to the Contract. Contractor must update its operational plan within forty-eight (48) hours of making approved changes and ensure that all employees performing services under the Contract are aware of the change(s).

1.1.2 Coordination of Benefits Services

Contractor will perform the following additional functions to ensure the coordination of benefits for THMP participants who are enrolled in the SPAP:

a. Adhere to the Centers for Medicare and Medicaid Services (CMS) Coordination of Benefits

(COB) guidelines dated January 2026 and any subsequent updates to these guidelines identified at: https://www.cms.gov/files/document/spap-dsa-user-guide-january-2026.pdf.

b. Coordinate benefits with all Medicare Part D Plans in the State of Texas, without discrimination, based upon the Part D plan in which the participant is enrolled.

c. Ensure that the SPAP does not pay for medication(s) that are classified as excluded from coverage under the Medicare Part D formulary by reviewing CMS-provided data and updates at a minimum upon release and incorporating such updates into claims adjudication processes prior to processing affected claims.

d. Maintain operations that satisfy all federal requirements to be considered a qualified SPAP under the Medicare Part D prescription drug benefit.

e. Manage the electronic data sharing process with CMS as outlined in the SPAP Data Sharing User Guide. (https://www.cms.gov/files/document/voluntary-data-sharing-agreement-user-guide-version-2-6-january-2026.pdf).

https://www.hhs.gov/hipaa/for-professionals/privacy/index.html https://www.hhs.gov/hipaa/for-professionals/security/index.html https://www.cms.gov/files/document/spap-dsa-user-guide-january-2026.pdf https://www.cms.gov/files/document/voluntary-data-sharing-agreement-user-guide-version-2-6-january-2026.pdf https://www.cms.gov/files/document/voluntary-data-sharing-agreement-user-guide-version-2-6-january-2026.pdf

RFP No. HHS0017240 Exhibit J

f. Maintain a unique Prescription Benefit International Number (Rx BIN) and Pharmacy Benefit Processor Control Number (PCN) for the SPAP.

g. Ensure the Contractor’s Rx BIN and PCN are reported to the National Council for Prescription

Drug Programs (NCPDP), CMS and the Medicare Part D Transaction Facilitator.

h. Ensure the claims processed for SPAP members include the correct Rx BIN and PCN.

i. Coordinate the administration of copayments and premiums under THMP.

j. Administer a claims adjudication process for each participant enrolled in a THMP insurance assistance program to determine payment of approved claims at the point of sale.

1.1.3 Administrative Requirements

a. Contractor shall assign and maintain a dedicated account manager responsible for oversight of Contract implementation, system functionality, and training coordination. The account manager must be available to meet with DSHS as needed for operational or urgent matters and must respond to all inquiries submitted by DSHS within 24 business hours.

b. Contractor must provide copies of agreements between the Contractor and any Subcontractors, including the pharmacy network, to DSHS for review and approval prior to document execution. These agreements should include information on Public Health Service (PHS) designated pharmacies and PHS contracted pharmacies. Agreements should not be finalized or implemented until written approval is received from DSHS.

c. Contractor must provide DSHS with a list of participating pharmacies no later than January 1st each year on an annual basis as well as any new enrollments or changes in the network for pharmacies. DSHS may exclude participation of pharmacies, or new enrollment for pharmacies and retain authority to exclude medications from coverage on a case-by-case basis.

d. All plans, policies, procedures, and schedules referenced in this SOW must be made available at the initiation of the Contract for on-site review by DSHS and must be consistent with DSHS policies.

1.2 TRAINING

Contractor shall provide training to DSHS staff on how to access the system, how to view claims and enrollment and any additional functions and capabilities. Additional refresher training shall be provided as requested on no more than a quarterly basis. Contractor shall provide DSHS staff with a data dictionary and a guide on how to run reports within the system.

1.3 REPORTING

Contractor shall provide the following scheduled reports and any other report(s) that may be available from the Contractor. Contractor shall deliver the reports in accordance with the schedules

RFP No. HHS0017240 Exhibit J and requirements identified in Section 1.4 (Deliverables) of this SOW. If Contractor fails to timely provide the reports as required under the Contract, DSHS may assess remedies against Contractor in accordance with the guidelines stated in Section 1.6 (Remedies).

a. Contractor shall submit reports as outlined in Section 1.4 (Deliverables) of this SOW. In addition, all Contractor services supported with DSHS funds must include the fee for each unit of service in its reporting. Premium payment reports must be broken down by premium type and by individual versus scheduled payments, and should include payment details such as check numbers, when payments were made, and when payments were posted.

b. Contractor shall respond to all special reporting requests made by DSHS within 48 hours of request. Special reporting requests may include, but are not limited to, providing a list of all active Public Health Service (PHS) pharmacies contracted with the PBM, and monthly premium payment assistance processed during a particular time period broken down by program type.

c. Contractor shall maintain a Reporting Data Dictionary, including a field‑to‑report mapping, that clearly identifies source data elements, business definitions, transformation logic, and the reports in which each field appears. This will be updated and shared with DSHS staff whenever new data fields or new reports are added to the Contractor’s database. Changes to report logic, definitions, or fields require prior written approval from DSHS.

1. The data dictionary should include at a minimum:

i. Field name;

ii. Definition;

iii. Data type;

iv. Allowed values; and

v. Business meaning (what does this data element mean to the program)

2. Field‑to‑Report Mapping Matrix should include at a minimum:

i. Source field;

ii. Report name;

iii. Report column;

iv. Business rule; and

v. Business meaning (documentation of how the field is calculated, what conditions must be met for it to appear, what values are included or excluded, and how the field should be interpreted).

d. Contractor shall submit all completed reports and data collection activities in accordance with the requirements of the SOW in order for reimbursement vouchers to be processed by DSHS.

RFP No. HHS0017240 Exhibit J

1.4 DELIVERABLES

Contractor shall meet all requirements set forth in this SOW including providing all Deliverables set forth in Table 1 - Deliverables. Contractor shall provide additional information, if deemed necessary by System Agency, in connection with System Agency’s review of a Deliverable for compliance.

Table 1 - Deliverables

Deliverable Description Due Date

Operational Plan Fourteen (14) calendar days after Contract Effective Date.

Transition Plan Thirty (30) calendar days before the Contract Effective date.

Turnover Plan Fifteen (15) calendar days after Contract Effective Date and each anniversary of the Effective Date, during the Contract Term.

340B Rebate Report Quarterly based on calendar year.

Claims Level Data Reports 1st Friday of each month.

Claim Adjustments Report Bi-monthly with invoice.

Premium Payment Report Monthly with invoice.

Adjudication Limitations Reports Friday of each week.

Annual Benefits Reports Annually, on the anniversary of the Effective Date during the Contract Term.

Compliance Reports Quarterly after the Effective Date of the Contract.

Quarterly Conference Call and Written Report Quarterly based on calendar year.

Pharmacies List Annually (January 1st) via the Contractor system.

RFP No. HHS0017240 Exhibit J

Special Reporting Requests Within 48 hours requested by DSHS.

1.5 KEY PERFORMANCE MEASURES

DSHS will monitor the performance of the Contract to ensure that all Services and Deliverables are provided in accordance with the requirements of the SOW, and in a manner consistent with industry standards, customs, and practices.

Without waiving the enforceability of any Contract terms and conditions, DSHS will use performance measures to assess Contractor’s effectiveness in providing the Services described in this SOW. These performance measures include, but are not limited to:

a. Timely payment of prescription claims, as needed, for each participant enrolled in THMP.

This means that the clams are adjudicated and paid at the point of sale in real time to prevent delays in participants accessing medications at the pharmacy.

b. Submission of required program data, including identification and resolution of payment errors in accordance with Section 1.1.1(i) (Coordination of Payment Services) of this SOW.

c. Report of SPAP enrollee out-of-pocket payments to the CMS True Out-of-Pocket Costs (TrOOP) facilitator in accordance with the CMS guidelines found in the Medicare Prescription Drug Benefit Manual located at: https://www.cms.gov/Medicare/Prescription- Drug-Coverage/PrescriptionDrugCovContra/Downloads/Chapter-14-Coordination-of- Benefits-v09-17-2018.pdf and Technical Memorandum that provides Changes to True Out-of-Pocket (TrOOP) Costs and the Calculation of the Maximum Monthly Cap for the Medicare Prescription Payment Plan https://www.cms.gov/files/document/hpms-medicare-prescription-payment-plan-troop-memorandum.pdf

d. Organize, at least quarterly, a THMP/PBM Contractor conference call to discuss programmatic issues that occurred during the previous quarter. The PBM shall submit a written summary of each call to DSHS within two (2) weeks of the call. DSHS may request an action plan from the PBM regarding programmatic issues or deficiencies that were identified. Such action plans are due to DSHS within two (2) weeks of the date they are requested. Contractor must take actions directed by DSHS following System Agency’s review of the plan submitted and must do so within the timeframes directed by DSHS. DSHS also reserves the right to direct actions, which the Contractor must follow, to address issues/deficiencies identified during such conference calls without first requesting an action plan from the Contractor.

e. At a minimum, Contractor’s help desk staff must be available between the hours of 8:00 a.m.

– 7:00 p.m. Central Standard Time, Monday through Friday. Availability of bilingual English/Spanish staff is required.

1.6 REMEDIES

The System Agency reserves the right to hold Contractor accountable for breach of contract or https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Chapter-14-Coordination-of-Benefits-v09-17-2018.pdf https://www.cms.gov/files/document/hpms-medicare-prescription-payment-plan-troop-memorandum.pdf https://www.cms.gov/files/document/hpms-medicare-prescription-payment-plan-troop-memorandum.pdf

RFP No. HHS0017240 Exhibit J substandard performance and may take remedial or corrective actions in accordance with Section

9.1 (Contract Remedies) of Exhibit B, HHS Uniform Terms and Conditions – Vendor, Version 3.4.

Once the System Agency has determined to assess remedial or corrective actions, the System Agency may notify the Contractor of the assessment(s). Failure to notify does not affect the System Agency’s assessment of remedial or corrective actions and is not a condition precedent to an assessment of remedial or corrective actions.

SYSTEM AGENCY RESERVES THE RIGHT TO HOLD CONTRACTOR ACCOUNTABLE FOR BREACH OF

CONTRACT OR SUBSTANDARD PERFORMANCE. THIS INCLUDES, BUT IS NOT LIMITED TO, THE

FAILURE OF CONTRACTOR TO TIMELY PROVIDE SYSTEM AGENCY WITH REPORTS IN

ACCORDANCE WITH THE REQUIREMENTS OF TABLE 1 IN SECTION 1.4 (DELIVERABLES), WHICH

MAY RESULT IN THE CONTRACTOR BEING ASSESSED REMEDIAL OR CORRECTIVE ACTIONS

1.7 INVOICE AND PAYMENT

a. Contractor shall request payment using the State of Texas Purchase Voucher (Form B-13), https://www.dshs.texas.gov/contractor-forms, and required supporting documentation (provided by DSHS) for reimbursement of the required Services/Deliverables.

1. Vouchers and any supporting documentation for medication administration reimbursement must be submitted bi-monthly on the 15th and last day of each month.

2. Vouchers and any supporting documentation for premium payment reimbursement must be submitted no later than the 30th of the following month.

3. Vouchers and supporting documentation shall be mailed or submitted electronically to all the addresses/email addresses below:

Claims Processing Unit, Mail Code 1940 Department of State Health Services 1100 West 49th Street

PO BOX 149347

Austin, Texas 78714-9347 EMAIL: Invoices@dshs.texas.gov

b. Contractor will be paid on a fee-for-service basis and in accordance with Section 2.1 (Prompt Payment) of Exhibit B, HHS Uniform Terms and Conditions – Vendor Version 3.4.

c. Contractor’s services will be invoiced and reimbursed as follows:

1. Per claim adjudication fees, billed monthly.

2. Cost reimbursement for premium payments and medication costs.

3. Monthly reconciliation of all enrollee claims.

http://www.dshs.state.tx.us/grants/forms/b13form.doc https://www.dshs.texas.gov/contractor-forms mailto:Invoices@dshs.texas.gov

RFP No. HHS0017240 Exhibit J

4. Premium payment fees that are invoiced monthly.

5. Service-related fees that are invoiced on a bi-weekly basis.

1.8 OPERATIONAL PLAN

Contractor shall provide an Operational Plan for implementing services to THMP and its clients as the Pharmacy Benefits Manager within fourteen (14) days of the Contract Effective Date. The operational plans must include details of how the Contractor will coordinate payment services, coordinate benefits services, meet administrative requirements, training, reporting, and achieve the required deliverables as outlined in this SOW.

1.9 TRANSITION PLAN

Contractor shall provide a Transition Plan for implementing the transition of its operations to all the programs/facilities with 100 percent operating levels no later than the Operational Start Date.

The Transition Plan must identify all tasks to be performed to transition, from the incumbent vendor. The Transition Plan must include all Deliverables, activities, materials, products, Services, and reports set forth in this SOW. Contractor shall submit the Transition Plan at least thirty (30) calendar days before Contract Effective Day in order ensure no contract coverage gap.

1.10 TURNOVER PLAN

Contractor shall provide to System Agency a Turnover Plan by the due date set forth in Section

1.4 (Deliverables). Contractor shall also develop a Turnover Plan for each anniversary of the Effective Date thereafter. The Turnover Plan must include detailed policies and procedures that will ensure the least disruption in the delivery of the Work during the turnover to DSHS/HHSC or its designee. The Turnover Plan must include all required documentation and data, ensure secure complete transfer of information, and help maintain service continuity for members and providers during the transition phase. The Contractor shall be willing to commence the turnover of any business or technology components at the request of System Agency.

1.11 ACCEPTANCE CRITERIA

Contractor shall provide to DSHS all Deliverables by the specified due date. DSHS will monitor, review, and approve the submitted Deliverables. If there are issues with the identified Deliverable, DSHS may request an action plan from the Contractor. The action plan is due to DSHS within two

(2) weeks of the date they are requested. DSHS reserves the right to direct actions, which the Contactor must follow, to address issues/deficiencies identified without first requesting an action plan from the Contractor.

1.12 TEXAS RISK AND AUTHORIZATION MANAGEMENT PROGRAM

The Contractor shall comply with the program requirements of TX-RAMP, if online portal is a SaaS. Commencing on the Effective Date, the Contractor shall have achieved TX-RAMP Level 2

RFP No. HHS0017240 Exhibit J

Certification, and the Contractor shall maintain such certification for the duration of the Contract Term. At the sole discretion of System Agency, the Contractor’s attainment of TX-RAMP Provisional Certification may satisfy the TX-RAMP Certification Level 2 requirement for the length of active TX-RAMP Provisional Certification. If System Agency permits TX-RAMP Provisional Certification, the Contractor is solely responsible for obtaining and maintaining TX- RAMP Level 2 Certification prior to the expiration of TX-RAMP Provisional Certification.

Contractor acknowledges that System Agency shall not provide Agency-sponsored Interim Provisional Certification or otherwise assist Contractor in Contractor’s compliance with TX- RAMP requirements.

In addition, Contractor shall:

a. Upon System Agency’s request, provide Contractor’s submission(s) to DIR that supports DIR’s approval of certification status and respond to System Agency and DIR TX-RAMP staff inquiries promptly;

b. Provide written notification to System Agency of any lapse in TX-RAMP certification including, but not limited to, DIR revocation of TX-RAMP certification within two (2) Business Days of Contractor’s discovery of non-compliance with TX-RAMP requirements;

c. Complete all TX-RAMP monitoring reports required by DIR and submit copies of reports to System Agency on or before the second (2nd) Business Day following the DIR submission deadline;

d. Routinely assess and monitor for compliance with required security controls and demonstrate that the security posture of the cloud computing Services offered is acceptable to maintain TX-RAMP certification;

e. If the Contractor has TX-RAMP Provisional Certification, provide a progress update to System Agency on Contractor’s application for TX-RAMP Level 2 Certification no later than the third (3rd) Business Day of each calendar month, unless System Agency requires more frequent reporting, until the expiration of the TX-RAMP Provisional Certification;

and

f. If the Contractor has TX-RAMP Level 2 Certification, commencing six months prior to the expiration date of the TX-RAMP Level 2 Certification, provide a progress update to System Agency on Contractor’s application for renewal or extension of its TX-RAMP Level 2 Certification no later than the third (3rd) Business Day of each calendar month, unless System Agency requires more frequent reporting.

The Contractor’s failure to comply with any TX-RAMP requirements including, but not limited to, continuous maintenance of the minimum certification required by the Contract may constitute

RFP No. HHS0017240 Exhibit J a material breach of Contract, and System Agency reserves the right to hold Contractor accountable by taking any remedial or corrective actions available under the Contract, at law, or in equity. If Contractor is unable to achieve TX-RAMP Level 2 Certification or re-certification, as applicable, for any reason before the 120th Calendar Day prior to the expiration date of the TX- RAMP Provisional Certification or TX-RAMP Level 2 Certification, as applicable, the Contractor shall provide, at no cost to System Agency, turnover Services in accordance with Section 1.10 (Turnover Plan).

System Agency reserves the right to confirm TX-RAMP certification status on the DIR website and request additional information from a Respondent to supplement the TX-RAMP documentation submitted in its Solicitation Response.

TX-RAMP Provisional Certification does not indicate compliance with TX-RAMP security baseline standards of a cloud computing service product.