Questionnaire No. 3 (Revised) - Prescription Drugs (Rx).pdf

Questionnaire for RFP No. 2130386 City of Miami Revised Questionnaire 3

Prescription Drugs (“Rx”)

Completion of this questionnaire is not mandatory, but it is strongly encouraged as failure to do so could negatively impact the overall evaluation score of the Proposal. Responses will strengthen your technical evaluation and may contribute to your overall proposal score. Please answer in the order presented. Incomplete responses may affect scoring.

I. Experience & Compliance

1. Does the Proposer have a drug exception form for doctors? If so, provide a sample.

2. Confirm compliance with Florida HB 1550, including:

a) Registration and reporting requirements;

b) Notification of price increases;

c) Compliant resolution cooperation with the Florida Department of Financial Services (FDS)

d) Attach summary or documentation of compliance procedures

II. Dispensing Fees & Discounts

1. What are the Proposer’s dispensing fees?

2. Are there any other fees associated with the Proposer’s RX proposal?

3. Provide discounts from Average Wholesale Price (AWP) for brand, generic, and mail order.

4. Describe any injectables, specialty medications or manufacturer discount/rebate programs.

III. Formulary & Clinical Programs

1. Provide a copy of your current formulary

2. How often is the formulary updated?

3. Describe

a. Pre-authorization and step therapy protocols;

b. Grandfathering options for plan transitions;

c. Introduction process for new drugs and urgent Federal Drug Administration

(“FDA”) changes;

d. Any exclusions and rationale.

4. Is your formulary evidence-based?

5. Provide top five (5) non-formulary drugs (specialty and non-specialty).

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Prescription Drugs (“Rx”)

6. Outline clinical programs available at no charge (e.g. diabetes, asthma, hypertension)

IV. Pharmacy Network

1. Describe the proposed national pharmacy network

2. Provide a provider directory

3. Confirm 95% or greater retail pharmacy coverage

4. Describe the process for enrolling in a pharmacy if found to be essential.

5. Do you offer

a. Toll-free customer service?

b. Online pharmacy locator tools?

c. Multilingual phone support?

d. Real-time claim access for members and consultants?

V. Claims Processing (Retail, Mail-Order, and Specialty)

1. Describe the claim processing system, location, and backup/disaster recovery plan.

2. Include turnaround time, system uptime, and audit trail access.

3. Outline security and Health Insurance Portability and Accountability Act (“HIPAA”) compliance protocols.

4. Describe retail and mail-order processes: submission, refill, fulfillment, payment.

5. What are the procedures for error handling, emergency fills, and audit recoveries?

VI. Reporting

1. Provide a list and schedule of standard and ad hoc Rx reports.

2. Confirm availability online and with approved consultants.

3. Include sample reports:

a. Claims Summary

b. Top Drug Utilization

c. High Claimants

d. Formulary Savings and Rebates

e. Grievance Tracking

4. Confirm full data file access monthly and post-termination.

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Prescription Drugs (“Rx”)

VII. Implementation Plan & Timeline

1. Provide a proposed implementation timeline from award through January 1, 2027.

2. Include:

a. Key tasks and responsible parties;

b. Eligibility file loading;

c. Distribution of member materials;

d. Training and communication plan.

3. Describe the mail-order transfer and onboarding process.

4. State the minimum time needed for a smooth transition.

VIII. Administrative Fees & Additional Charges

1. Outline base admin fees (per claim or Per Employee Per Month (“PEPM”)).

2. List all additional charges (e.g. for edits, programming, materials).

3. Indicate which services are optional vs. included.

4. Are reversals subject to admin fees?

5. Provide billing samples and methods.

IX. Rebate and Cost Reduction Programs

1. Is the City eligible for rebate or cost reduction programs?

2. Provide:

a. Rebate guarantees ($/Rx, % ingredient cost);

b. Timing and method of rebate remittance;

c. Transparency of manufacturer contracts and rebate terms.

3. Confirm acceptance of:

a. Full economic disclosure requirements;

b. Quarterly rebate payment timelines (with 10% monthly interest if late).

X. Drug Utilization Review (“DUR”) & Medication Management

1. Describe your DUR program, including point of sale and retrospective edits.

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2. Include criteria such as:

• Drug interaction;

• Duplicate therapies;

• Age/gender edits;

• Early refills.

3. Provide Sample DUR reports.

4. Describe medication management services and pharmacist involvement.

XI. Audit

1. Describe the Proposer’s audit program. Include a description of how providers are selected for (desk and on-site) audits, how often audits occur, and how settlements are calculated.

XII. Performance Guarantees

1. Outline guarantees with financial penalties, including:

a. Implementation accuracy;

b. Claims processing performance;

c. Customer service metrics;

d. Satisfaction surveys;

e. Timely and accurate reporting.

2. Confirm all guarantees stand alone and are not offset

XIII. Summary of Key Issues

1. Please confirm the following (Yes/No and a brief explanation if ”No”):

a. All Claims billed at the exact amount paid to the pharmacy

b. Maximum Allowable Cost (“MAC”) Pricing guarantee for all generics.

c. Full rebate accounting, including admin fees.

d. City may independently contract with a specialty pharmacy.

e. Grandfathering support across all benefit areas.

f. Free transfer of historical data upon termination.

g. Collaboration with carrier/TPA for Affordable Care Act (“ACA”) compliance.

h. Quarterly MAC pricing reviews with City.