PBMS Q2 Response.7.16.25.docx

STATE of ILLINOIS

HEALTHCARE AND FAMILY SERVICES

SOLE ECONOMICALLY FEASIBLE SOURCE

2024-22-004 / 26-478HFS-MEDPR-B-48652

PBMS Q2 Response PBMS Required Specifications

1. The Pharmacy Benefit Management (PBM) Portal shall provide a secure portal for accessing applications, high-level summary information, and access to the business activity log. The portal shall also allow for central user management for administrative access and controls by administrators.

2. The RxPortal shall provide State staff with real-time access to claims data, drug formulary, Preferred Drug List (PDL) information, and approved prior authorizations (PAs) through a secure, web-based user interface. The RxPortal shall maintain its own audit table of activities that is accessible from the Point of Sale (POS) Control Panel and accept and process pharmacy claims submitted by pharmacy providers via POS devices or switch vendors.

3. The Formulary Application shall manage drug coverage status with rule sets for the RxPortal (POS) system. The application shall monitor and create the National Drug Code (NDC) level drug feed to the POS. State Maximum Allowable Cost (SMAC), Medicaid Rebate, Medicare Part B, and Part D, and Drug Reference data shall be able to be monitored and exported to the POS through the Formulary Application. HFS drug lists shall be created and maintained using secondary rule sets to augment NDC data.

4. The Illinois Pass Through Attributes (PTA) Formulary (Version 4.7) shall manage the preferred drug list including class and status through PTA rules. The application shall produce the weekly analytics report sets which include: IL_PTA_Formulary_PDL_NDC_To_MCO; IL_PTA_Formulary_PDL_Public_Facing; and IL_PTA_Formulary_PDL.

5. Preferred Drug List (PDL) Management System shall function as a Drug List Management tool that allows users to indicate the preferred drug list status of an individual drug item. The PDL is embedded within the RxPortal Point-of-Sale (POS) system. Some key features of the PDL application that shall be usable include: Importing drug information files from Medi-Span, setting preferred/non-preferred status on new and existing National Drug Codes (NDCs), creating and updating PDL categories, assigning new and existing NDCs to PDL categories, setting PDL and NDC exceptions and exporting the PDL data to the POS system for use in claims adjudication.

6. The Prior Authorization Decision Support System (PADSS) shall function as a management tool used to facilitate clinical review and real time processing of pharmacy Prior Authorizations (PAs). PADSS is used to determine manual/clinical PAs that have been submitted by prescribers and pharmacists, and interfaces with the Point-of-Sale (POS) System to exchange PA data. This ensures that approved clinical PAs are available for a patient when his or her pharmacy requests payment for a claim, completing the PA workflow process.

7. The Decision Support System (DSS) application shall provide a quick and easy method to run lookups and structured queries against the pharmacy Medicaid datasets such as claims, eligibility, prescribers, pharmacies, PAs, drugs, or any other reference data that is available. It shall return results based on criteria provided by the user into pre-defined dataset queries.

8. The Illinois Provider Portal shall serve as a Web-based collection of tools for Prescribers, pharmacies, and Healthcare and Family Services (HFS) staff at a minimum. The portal shall provide a secure interface for Providers to look up participant eligibility, participant history, drug formulary information, Preferred Drug List (PDL) criteria, and submit and confirm Prior Authorization (PA) requests online.

9. The DeepSee Analyzer shall support the creation of pivot tables, which display aggregated data. Each pivot table is based upon a subject area or a cube. When accessing the Analyzer, subject area selection shall be available, as well as subsequent displayed elements defined in that subject area, which can be used to create pivot tables.

10. The SQL Server Reporting Services (SSRS) Report Manager shall function as a Web-based report access and management tool used to browse the report server folders or search for specific reports.

11. Retrospective Drug Utilization Review (RetroDUR) shall serve as a survey tool which allows the user to manage documents, track provider inquiries and record provider responses pertaining to RetroDUR initiatives. RetroDUR shall manage the many tasks associated with creating, distributing, and collating responses to participant profiles.

12. Drug Rebate Program: The Illinois Drug Rebate Program Is maintained by the Drug Rebate Unit (DRU) within the Bureau of Budget and Cash Management (BBCM) at HFS. The DRU uses a series of manual rate calculations, conversions and ad hoc updates to manage the State's Drug Rebate Program. The DRU maintains processes for Invoicing drug manufacturers, reconciling payments, resolving manufacturer disputes, and reporting for federal and State-only rebates. In addition to federal rebate processing, HFS negotiates supplemental and State only rebates. Supplemental drug rebates provide HFS with rebates greater than those provided through federal rebate rates. State-only rebates are negotiated with manufacturers of medical supplies (e.g., diabetic aids, monitors, test strips). The PBMS shall accumulate data required to calculate and Invoice drug rebate payments from drug manufacturers participating in the federal and State Drug Rebate Programs.

12.1. Drug Rebate Management System (DRM)

12.1.1. The Rebate Admin ‘Contact Management’ application shall function as the rebate web application for staff responsible for the management of Labeler and Manufacturer Contact information. This includes performing the following tasks: managing labeler/manufacturer eligibility and adding, maintaining, and organizing labeler/manufacturer contacts.

12.1.2. Electronic Rebate System (eREBS), shall function as a total Rebate Management System where users can manage the invoicing and collection of drug rebates. The eREBS system allows the user to: create invoice, generate the CMS utilization file, review invoices, track rebate receivables, review claims, review and manage disputes, select reporting; and create doc prep sheets for scanning.

12.1.3. Rebate Scanner shall function and be used by the Drug Rebate Unit, Rebate Specialists whereas when a document is received, DRU Staff can review, process, scan, and upload manufacturer correspondence into an electronic database system. Properly associating documents to the appropriate manufacturer, year, and quarter is important to ensure manufacturer accounts are balanced and can be audited at a later date.

12.1.4. Rebate Services Portal shall function and be used by the Drug Rebate Unit, Rebate Specialists whereas when a document is received by DRU Staff can review, process, scan, and upload manufacturer correspondence into an electronic database system. Properly associating documents to the appropriate manufacturer, year, and quarter is important to ensure manufacturer accounts are balanced and can be audited at a later date.

12.1.5. Scanning/Record Retention System (formerly Alfresco) shall function as the system for the dug rebate unit. All documents scanned shall be stored, retained, and available from within the system (formerly Alfresco). Invoices shall be able to be exported from eREBs to the system (formerly Alfresco) once they have been created.

13. Workflow Automation: PBMS workflow automation shall guide system users through various business activities which will be established for recurring sets of business operations that are done within the context of established procedures.

14. Rules Engine Configurability: A rules-based solution which allows HFS to respond to changes more quickly in the business environment. Many routine system logic changes may be made with minimal Involvement of the Vendor. The rules-based solution will produce automated documentation of the current rules in effect as well as the history of all rules implemented and will reduce many of the manual steps in communicating system changes to programming staff.

15. Web Based User Interface: shall automate and standardize communication with providers an Internet web-based portal accessible to pharmacies, prescribing providers and HFS staff. The portal provides capabilities such as input and viewing of prior authorization requests and dispositions, direct data entry of claims by pharmacy providers and HFS staff, interactive provider help, secure email between HFS and providers, and submission and response of transactions other than the POS transactions. The portal shall allow for publication of drug rebate invoices and submission of drug rebate payments and associated data. Automated capture of all communications with providers, manufacturers, and any other external entities through the portal(s) will be retained in a customer relationship management (CRM) repository which will be accessible online by HFS staff to be aware of all previous correspondence with the stakeholder and to be able to make notations of their telephonic discussions with the stakeholder.

16. Claims Processing / General: The PBMS shall maintain current and historical reference data used in claims processing

17. POS Claims Adjudication: The PBMS shall support real-time adjudications of pharmacy claims. Claims, compliant with the NCPDP standard, are received by the PBMS via a switching network that connects all of the HFS-enrolled pharmacy providers to the PBMS. The pharmacy claims are received, converted to a schema compatible to the PBMS, and presented for adjudication. A set of edit and audit rules, member eligibility information, member historical information, and the drug formulary are applied to each claim to determine If HFS will pay the claim and how much HFS will pay. The result of the adjudication process is that the pharmacy provider receives a real-time response from the PBMS for each claim. The adjudicated claims are subsequently forwarded to the Medicaid Management Information System (MMIS) on at least a daily frequency for payment final disposition and Enterprise Data Warehouse (EDW) data population. A copy of all pharmacy POS claims is maintained in the PBMS data files.

18. Claims Payment Processing: The POS system shall provide real-time adjudication of claims. The adjudicated claims will be accumulated within the MMIS in a pending file until they are released for payment. Claims released for payment are aggregated into payment vouchers and remittance advice transactions are prepared to accompany the payments. HFS does not plan to revise or replace the pending file process that is native to the existing MMIS. The PBMS will forward adjudicated claims to the MMIS for payment processing. Adjudicated claims will be forwarded from the PBMS to the MMIS in an HFS-specified format for payment processing and EDW data population. Additionally, the PBMS will adjudicate pharmacy claims in real time and apply a financial fund matrix so that funds can be allocated by claim type. The foregoing information shall be forwarded to the MMIS for financial processing and reconciliation.

19. Prior Authorization: The POS system supports submission of prior authorization requests electronically; however, the majority of prior approval requests are received by phone. A subset of requests Is submitted by fax. The prior approval requests and requests for exceptions to refill-too-soon denials are distributed via an electronic queue to the pharmacy consultants for their review. Approved requests are retained in the Prior Approval database where they can be accessed during claims processing. Notices of the disposition of the prior approval request are communicated back to the member and to the originating provider.

20. State Pharmaceutical Assistance Program (SPAP) The Vendor will be required to implement the Prescription Drug Event Processing for the State Pharmaceutical Assistance Program (SPAP).

20.1. Illinois is approved for and currently operating a SPAP and shall claim supplemental rebate from manufacturers beginning with dates of service on or after 01/01/2024.The PBMS shall adjudicate these SPAP claims and allow for entry of the contracts into the rebate system for separate invoicing to drug manufacturers.

20.2. Coordination of Benefits: The HFS Bureau of Collections (BOC) is responsible for avoiding HFS payment of medical expenses when a member has other health insurance and for recovering HFS-paid client medical expenses from third parties liable for the payment of those expenses. Since Medicaid is the payer of last resort, all attempts are made to identify other responsible payers. Any third-party liability (TPL) payment amount reported on a claim is deducted from the amount payable by HFS. Any claims for members who have known or suspected third party insurance coverage are flagged for TPL subrogation. HFS' post-payment TPL subrogation of paid claims is effective at recovering payments for claims for which TPL was not known at the time of adjudication.

21. Cost Avoidance: The PBMS shall enhance the cost avoidance capabilities of HFS by providing coordination of benefits (COB3) functionality; ensuring that Medicaid remains the "payer of last resort”.

22. Formulary and Rates Maintenance: The PBMS shall provide a formulary management service for HFS Medicaid program Fee for Service (FFS) and managed care that includes but not limited to the maintenance of the granular NDC level HFS formulary as well as a public facing HFS Preferred Drug List (PDL).

23. Drug Data File: Vendor shall supply HFS with a Medispan and a First Databank drug file; a drug product database intended for use as an information source to assist in drug product data dependent applications and consists of an initial master file of data fields containing drug product information, utilization Information, and a User's guide.

24. Manufacturer Payment Processing: The manufacturer payment processing function shall provide functionality, using generally accepted accounting principles, for: receiving payments, posting payments, deleting payment discrepancies, generating past due notifications interfacing with SAP, reporting payments and shall provide numerous reporting functions.

25. Dispute Resolution Process: The dispute resolution process shall support all the activities of handling all payment amount disputes whether identified by manufacturers or by HFS.

26. State Maximum Allowable Cost (SMAC): The vendor shall ensure that only approved products covered by the department are included in the State Maximum Allowable Cost (SMAC) list.

27. Infrastructure and Technical Support: The Vendor shall host the PBMS in a commercial data center which shall be a Tier II or above facility with N+ 1 capability for all HVAC, electrical, UPS and generator facilities, HFS data shall never be physically located in or accessed from any facility outside of the USA, HFS data shall be segregated from all other customer data and Vendor shall ensure the confidentiality and integrity of all HFS data.

28. Pharmacy Claims Exchange Switch. The Vendor shall provide a dedicated and primary service to support the real-time exchange of claim and member eligibility information between the Pharmacy Providers and the PBMS. The Pharmacy Claims Exchange Switch shall be a communications network that will be available 24-hours a day, 7-days a week.

29. PBMS Hosting Services: The Vendor shall provide an on-premises solution for the PBMS. The PBMS shall be maintained in a primary data center site with a hot failover capability of the PBMS production environment will be provided in a secondary disaster recovery site located at least 90 miles from the primary site. This capability will be periodically tested and validated as a part of the Disaster Recovery Plan. This capability shall be invoked during system maintenance and for any unexpected but recoverable outage of the PBMS at the primary site.

30. Application Support: PBMS Change Control Process. HFS shall allocate a block of hours at the start of each contract year, for system modifications requested and approved by HFS that may be required and are not possible by modification of the workflow or business rules engine. The Vendor will be tasked to provide technical support for any elements of the PBMS that are the result of customizing software or Vendor-developed interfaces specific to HFS. The block of hours will be used by the Vendor and will be managed by task order(s) assigned by HFS.

31. Audit Compliancy The Vendor will be responsible to comply with the Control Objectives for Information and Related Technology (COBIT) audit framework and respond to any audit findings in a timely fashion as specified by the audit report.

32. Contract Closeout Plan. The Vendor shall produce a Project Transition Plan that details the activities that shall be performed to close out the contract and transition all State-owned resources back to HFS or to another vendor. The plan shall include:

32.1. Submission of Draft Closeout Work Plan within 180 calendar days prior to contract closeout; submission of Final Closeout Work Plan within 90 calendar days prior to contract closeout.

32.2. Identification of key personnel by position or title who shall manage the close-out process.

32.3. Method for identifying all State data that shall be transitioned to an agent identified by HFS.

32.4. Format and media type that shall be used to transition data to an agent identified by HFS.

32.5. Methodology that shall be used to ensure that NO State data remains anywhere within the existing servers or storage devices, removeable media, or hardcopy media once transition is complete.

32.6. Run-Off Services Agreement. Upon termination or expiration of the Agreement as a whole and/or in part, PBM agrees as follows with respect to the terminated Covered Plan(s), and/or Service, as applicable. For purposes of the Agreement (Post-Termination Services) only, (“Termination Date”) shall mean the last day of the Term or the Extended Services Period, as applicable, with respect to the terminated Covered Plan(s), and/or Service. This Agreements denote the specific responsibilities of the PBM upon Termination. Such services shall include, but not be limited to the following:

32.6.1. Payment by HFS for services provided prior to expiration/termination of the PBMS contract.

32.6.2. Transition Services

32.6.3. Cooperation of all parties (HFS, Awarded Vendor and/or Current Vendor)

32.6.4. Delivery of Data

32.6.5. Audit Support

32.6.6. Run-Out Claims

32.6.7. Rebates

32.6.8. Reporting

32.6.9. Termination Plan

32.6.10. Portability

32.6.11. Communications

32.6.12. HIPAA Compliance and Record Retention