PALISADE STRATEGIES Performance Work Statement FY25.pdf

Performance Work Statement (PWS)

VA Central California Health Care System

Pharmacy Benefit Management Services

1 PURPOSE:

a. This contract is to provide financial management services to ensure reimbursement of emergent fill pharmacy benefits. The contract is between VHA, as a health plan, and the contractor, for the purpose of reimbursing the Contractor a set price for prescriptions filled at the patient’s request for which the patient was not charged.

b. Contractor shall provide these services to the VA Central California Health Care System

(VACCHCS) patients and those receiving care through Community Based Outreach Clinics

(CBOCs). Locations served include VACCHCS located at 2615 E Clinton Ave Fresno CA 93703, Visalia CBOC located at 500 N Santa Fe Visalia, CA 93292, Oakhurst CBOC 40597 Westlake

Drive, Oakhurst, CA 93644 and Merced CBOC 340 East Yosemite Avenue Suite D Merced, CA

95340. The contractor shall provide coverage using a network of pharmacies located within a 5-mile radius of VACCHCS and the CBOCS. A list of pharmacies is attached for reference, but not limited to.

2. Procedures

a. The pharmacies with which the contractor have a business relationship shall only be reimbursed for prescriptions that were filled and dispensed from original prescriptions written by VA or VA contracted providers assigned to the CBOC.

b. In order to receive reimbursement, prescriptions filled by the contractor’s dispensing pharmacies will be in written form and in accordance with VA policy and procedures as well as applicable state and federal regulations. The contractor’s dispensing pharmacies must be able to accept the written VA Form 10-2577F, Security Prescription Form. Sample form is attached for reference.

c. Prescriptions reimbursed through the financial management services for emergent fill pharmacy benefits contract will be limited to medications of urgent need as determined by VA clinical staff and will follow safe and effective formulary management principles practiced with the VA. The adjudication of medications on a case-by-case basis must follow VACCHCS procedure. The VA pharmacist shall develop a list of emergent drugs that can be reimbursed for under the contract without prior authorization. The Chief of Pharmacy, or designee, will provide this “emergent drug list” to the contractor at the time of contract award and provide updates to the list as necessary. Generic drugs shall be used whenever available. All medications reimbursed for under this contract must meet FDA standards. The Chief of Pharmacy, or designee, will provide the VA National Formulary list to the contractor at the time of contract award and will provide updates to the list of necessary. https://www.pbm.va.gov/nationalformulary.asp

d. Prescriptions processed under this contract shall be filled with generic drugs to the extent permitted by law. Contractor pharmacist will select the least expensive generic drug product in stock. Contractor shall follow the same standards as the VA pharmacy when substituting generic products: same chemical ingredient, same strength, same dosage form as the branded product and an FDA therapeutic equivalency rating of “AB” for oral products or “AT” for topical products. Reference: FDA Electronic Orange Book at www.accessdata.fda.gov

e. Only NEW prescriptions shall be filled and dispensed by the pharmacy from original prescriptions written by VA providers. The Chief of Pharmacy may authorize refills under special conditions, i.e. after natural disasters.

f. All prescriptions shall be filled for the quantities as written, not to exceed a 14-day supply, except for those products that the manufacturer’s package size prohibits dispensing in a smaller quantity (e.g., inhalers, insulin vials).

g. Medical supplies, injectables and prosthetic items are not included in this contract except for emergency supply of insulin vials and syringes.

h. Pharmacies/Pharmacists will provide medication counseling to each patient, will include but not limited to:

i. Name, description, and use of medication

ii. Dose, dosage form and route

iii. Special directions and precautions

iv. Common side effects and action required if side effects occur.

v. Techniques for self-monitoring drug therapy

vi. Action to be taken if a dose is missed.

vii. Proper Storage

viii. What the patient can expect from the medication.

ix. The balance of the patient's prescribed medications will be mailed from the VA pharmacy.

i. Pricing information for the medications dispensed on claims can be determined by using the following, Medi-Span, Red Book, Good RX. Price is based on AWP less percentage for Generics and Brand.

3 . DOCUMENTATION:

a. The Contractor shall maintain documentation of prescriptions filled under this contract.

Documentation shall indicate the following:

I. date the prescription was filled.

II. prescription number

ii. patient’s first and last name

iii. patient’s last four of SSN

iv. drug label name

v. total quantity

vi. total day supply

vii. total ingredient cost paid

b. Invoices, along with the aforementioned documentation, will be submitted once per month via encrypted email to designated VACCHCS Pharmacy point(s) of contact (POC) and will include a request only for payment for services actually performed. VACCHCS Pharmacy POCs will authorize payment, and the invoice will be sent to VACCHCS Fee Basis staff for payment processing.

c. The Contractor shall provide quarterly reports on the usage, cost, and types of drugs being prescribed by CBOC physicians. Reports must include all reported errors, incidents and veteran related complaints.

d. All payments made under this contract will be made monthly in arrears in accordance with

Federal Acquisition Regulation (FAR) Clause 52.212-4. No advance payments will be authorized.

4. HOURS OF OPERATION AND SUPPORT:

Contractor will provide a customer service team to ensure that all pharmacy operations are performed in compliance with all VACCHCS, HIPAA and other regulatory requirements. The customer service team will assist with issues that arise regarding authorizations; prescription rejects or claims during normal business hours of 8:00 a.m. to 5:00 p.m. PST Monday through Friday, excluding federal holidays. Contractor shall respond to changes in need or new service requests within 24 to 48 hours.

5. CONTRACTOR QUALIFICATIONS

a. Contractor shall provide a national network that meets the following criteria:

i. Valid National Association of Boards of Pharmacies (NABP) issued by National Council on

Prescription Drug Programs (NCPDP);

ii. Maintain a current and valid DEA license;

iii. State pharmacy business license and permit; and

iv. Pharmacists must be licensed in the state in which they practice and have a current Scope of

Practice.

6. PERSONNEL HEALTH INFORMATION (PHI):

The contractor is prohibited from transferring Personnel health Information (PHI) by fax or email and /or from a VA Medical facility unless issued a VA PKI “partner” certificate to allow encrypted email exchange. Invoices, authorizations, and report can then be sent via PKI encrypted email. If prior authorization for the payment of an emergent pharmaceutical is necessary and the contractor does not have a VA issued PKI “partner” certificate, verbal contact is sufficient to obtain the pharmaceutical payment authorization. Contractor shall not store patient information on a mobile device

7. HIPPA COMPLIANCE

Under Health Insurance Portability and Accountability Act (HIPPA) Privacy and Security Rules, the

Contractor providing services under this contract is considered to be a “covered entity” and thus is not required to enter in a Business Associate Agreement with VASNHCS. However, the Contractor must observe Public Law 104-191 and all respective regulations implementing this law while providing services under this contract.

CONFIDENTIALITY OF PATIENT RECORDS

The Contractor, as a VA provider, shall assist in the provision of health care to patients seeking such care from or through the VA. As such, the Contractor is considered as being part of the

Department's health care activity. The Contractor is considered to be a VA provider for purposes of the Privacy Act, Title 5 U.S.C. 552A. Further, for the purpose of VA records access and patient confidentiality, the Contractor is considered to be a VA provider for the following provisions: Title 38

U.S.C. 5701, 5705, and 7362. Therefore, the Contractor may have access, as would other appropriate components of the VA, to patient medical records including patient treatment records pertaining to drug and alcohol abuse, HIV, and sickle cell anemia, to the extent necessary to perform his contractual responsibilities. However, like other components of the Department, and not withstanding any other provisions of the contract, the Contractor is restricted from making disclosures of VA records, or information contained in such records, to which it may have access, except to the extent that explicit disclosure authority from the VA has been received. The

Contractor is subject to the same penalties and liabilities for unauthorized disclosures of such records as the VA.

The records referred to above shall be and remain the property of the VA and shall not be removed or transferred from the VA except in accordance with U.S.C. 551a (Privacy Act), 38 U.S.C. 5701

(Confidentiality of Claimants Records), 5 U.S.C. 552 (FOIA), 30 U.S.C. 5705 (Confidentiality of Medical

Quality Assurance Records), 38 U.S.C. 7332 (Confidentiality of Certain Medical Records), and Federal laws, rules and regulations. Subject to applicable Federal confidentiality or privacy laws, the

Contractor, or their designated representatives, and designated representatives of Federal regulatory agencies having jurisdiction over the Contractor, may have access to the VA's records at the VA's place of business on request during normal business hours, to inspect, review, and make copies of such records.

(End of Performance Work Statement)