WVPEIA Bidder Questions 06.17.2025 Final.pdf

Response to WVPEIA PBM RFP Bidder Questions

Vendor Question Response

Who is the broker/producer for WVPEIA? Not applicable

I see there are 8,795 non-Medicare retiree members listed on page 5 of the Technical Proposal document.

Page 4 states: A smaller number of Medicare eligible members receive prescription benefits through the standard benefit and participate in the Centers for Medicare and Medicaid Services (CMS) Retiree Drug Subsidy (RDS) program. The population of Medicare eligible members fluctuates throughout the plan year ranging between 200 to 2,500.

Will we need to provide RDS reporting for 200 - 2500 Medicare eligible retirees?

The successful bidder will need to support RDS services for the Medicare eligible members as they age in each year. They are then transferred to the MAPD every January.

How long has WVPEIA been with ESI? The current contract was effective July 1, 2022.

Who is the medical carrier/TPA (carved-in or carved-out?)?

UMR

PBM is carved out with Express Scripts

Is this group also shopping medical? If so, who will be considered (checking for connectivity)?

No, not at this time.

I see that WVPEIA is looking for more flexibility to align with their objectives (lower net cost, trend management, access to the right drugs). Are there other specific pain points in the current arrangement?

Prescription cost trends increase year over year in unsustainable amounts. Specialty is consuming over 40% of the total drug spend and will continue to grow exponentially. PEIA’s top drugs are all specialty and diabetes medications. Thus, PEIA is looking for a partner with the flexibility, management programs and suggestions which will react quickly and proactively to this dynamic market and best manage this rapidly growing line of healthcare.

Do they currently cover GLP-1s for weight? No, GLP1s are only covered for type 2 diabetes with PA.

Is there a commission we will need to build into our underwriting? No commission – Not applicable

Is this a market check or is the plan actively pursuing a new PBM?

This is not a market check. This is an active RFP in pursuit of the best quantitative and qualitative results.

Is the plan currently on an open or closed formulary?

The formulary is Express Scripts National Preferred formulary.

This is a formulary with exclusions.

Does the plan have any major concerns regarding spend on certain drugs or a specific drug class? -

Prescription cost trends increase year over year in unsustainable amounts. Specialty is consuming over 40% of the total drug spend and will continue to grow exponentially. PEIA’s top drugs are all specialty and diabetes medications. Thus, PEIA is looking for a partner with the flexibility, management programs and suggestions which will react quickly and proactively to this dynamic market and best manage this rapidly growing line of healthcare.

Would the plan consider a net PMPM guarantee in lieu of traditional discounts or rebates? If yes, please confirm your member count quoted as this is an important piece of the PMPM calculation.

The member count provided is accurate. WVPEIA is looking for bidders to submit both a pass-through pricing proposal and a PMPM guarantee proposal as outlined in the Cost Proposal Template.

I have a quick clarifying question regarding the lines of business for this procurement. We don’t believe that there are EGWP lives included in the member population, or more accurately, that our proposal should have an EGWP component. Are you able to please either confirm or clarify if this is accurate?

No EGWP. The successful bidder will need to support RDS services for their Medicare eligible members as they age in each year. They are then transferred to the MAPD every January.

Will any hard copies of the RFP Submission be required? If yes, please clarify the number of copies along with a mailing address.

No hard copies are required – only electronic submission.

Will new addendums be submitted via email?

Yes, these will be submitted to those who have submitted their Intent to Bid, as well as posted on the WV vendor self-service website.

Will PBM invoice WVPEIA directly or through the TPA? The PBM will invoice WVPEIA directly.

Will ARMSRx accept redlines, specifically to Exhibits 3, 4, 5, 6, & 10?

Redlines for Exhibits 3, 4, 5, and 6 will not be accepted. Redlines for Exhibit 10 may be proposed, which will be considered.

With regards to redaction will PBM need to submit a redacted version of the Cost Proposal? WVPEIA has marked this as Proprietary and Confidential so please confirm that the information in that file will not be made public.

Please refer to Exhibit 9 - West Virginia Public Employees Insurance Agency Vendor Guidance on redaction for FOIA requests. This Exhibit outlines specific details relative to this question. Additionally, please see mandatory requirements page 26 for more information as follows:

Vendor understands that this RFP, any proposals, and any resulting contract is subject to public disclosure under the West Virginia Freedom of Information Act (FOIA). Vendor agrees to submit a redacted copy of its bid proposal within 15 business days of the bid closing date. After 15 business days of the bid closing date, if WVPEIA receives a FOIA request, the unredacted bid provided by the Vendor will be submitted in response if a redacted bid has not been provided.

Vendor will submit Redaction Attestation Form (Exhibit 8) to confirm understanding of the redacted bid requirements. The document “West Virginia Public Employees Insurance Agency Vendor Guidance on redaction for FOIA requests” for vendor guidance is also attached as Exhibit 9. Submission of a proposal constitutes confirmation that the vendor has read and understood these Exhibits.

References W. Va. Code § 29B-1-4 and W. Va. Code § 47-22-1(d).

In order to maintain consistency between the all-inclusive Pass-Through pricing proposal and the all-inclusive PMPM guarantee, please confirm that the exclusions referenced on the "Discount & Rebate Exclusion" tab (paper or member submitted claims, COB, vaccines, etc.) in the Cost Proposal Workbook would also apply to the PMPM guarantee?

This is not assumed. Both offers will be analyzed separately and WVPEIA will choose the best fit for their organization.

Please adhere to the discount and rebate exclusions as outlined in the cost proposal for the pass-through proposal.

Please adhere to the ONLY exclusions allowed for the PMPM guarantee model as outlined in the cost proposal, which indicates only catastrophic claims.

Exhibit 7: Bidders Litigation Waiver addresses the Request for Proposal for Life Insurance and Accidental Death and Dismemberment Services. Please provide the appropriate exhibit for this RFP.

A revised exhibit will be provided to remedy this inadvertent error. Please see attached.

Are all claims expected to be adjudicated using NADAC/WAC + $10.49 DF? Or just WVPEIA pharmacies and PBM Specialty?

As indicated in the RFP, NADAC/WAC + $10.49 Dispensing Fee is ONLY required for all WV domiciled pharmacies and the PBM specialty pharmacy.

Are additional discount/rebate exclusions accepted?

No, please adhere to the allowable exclusions as outlined in the cost proposal. All other categories are expected to be included in the guarantees.

Please provide a claims file with tier indicators in order for us to accurately match the current plan designs.

This is not being provided. There is a brand/generic indicator in the file. Generic is Tier 1, Preferred Brand is Tier 2, Non- Preferred Brand is Tier 3. There is also a formulary indicator in the file.

What is the client's ERISA status? Non-ERISA

Page 3 of the Technical Proposal document states ‘All responses must be provided in this template.’ Please confirm we can respond to all questions within our own template/letterhead as long as the format is not altered.

The preference is to respond in the template provided, however, as long as the format of the technical proposal is not altered, and is submitted in an unlocked format, it will be acceptable. For the cost proposal, this must be submitted in the template provided.

Section 1.3 (page 20): please confirm 1 email can be sent with BOTH the technical proposal response and the cost proposal response as long as they are clearly marked.

Yes, they can be submitted in one email as long as they are separate documents and clearly marked.

Attachments to Include (page 24), #2: Is an executable contract requested with our bid submission?

Please provide your contract template at this time. An executable version will be requested upon award notification with the expectation that all agreed upon pricing, provision, and terms will be translated to the final contract.

Attachments to Include (page 24), #12: do we need to provide an additional attachment with all of our agreed upon PGs or will responses to that section of the questionnaire (beginning on page 55) suffice?

Responses to the PG section of the RFP will suffice at this time.

Attachments to Include (page 24), #17: please confirm this report does not apply if we are a privately-owned company and therefore do not produce an annual report.

Confirmed – please provide financial statements with independent auditor report in lieu of the 10-K report.

General Information (page 34): if there is more than one subcontractor providing supplemental services, should we add additional lines to the table for each subcontractor? There is only room for one subcontractor to be listed currently.

Yes, please add additional lines as necessary. You may also refer to and submit a list of your subcontractors as an attachment with your response.

1.4.2 (Page 8): Please confirm proposed contract price will be evaluated by use of the following formula: Lowest price of all proposals/Price of proposal being evaluated X 50 = Price Score (there is currently a ‘,’ between lowest price and Price of proposal being evaluated)

Yes, that is correct.

Clinical Management Programs (page 40): Does sub section (k) apply to this requirement? If so, how many prescriptions are required to be measured, evaluated, and approved/denied ‘exemption’ status?

Per W.Va.code 5-16-7f(k) the gold carding exemption does not apply to PBM.

Specialty Pharmacy (page 40) WVPEIA does not process ancillary services for medical benefit specialty medications through the PBM – only through the TPA.

Thus, PBM Specialty pharmacy and retail specialty pharmacies must bill TPA.

Will WVPEIA provide a list of the specialty medications required to be billed to the TPA?

No. As a rule self-administered oral and injectable medications are a pharmacy benefit. Healthcare professional administered medications are a medical benefit. The successful bidder will be required develop and maintain the specialty list for WVPEIA and the TPA based on this rule.

In the Account Management section of the Technical Proposal (page 35), please clarify what “direct” refers to in this question.

Confirm that the client will have direct or dedicated account team support for continuity of knowledge and history to expedite and support their needs.

We are requesting a “dedicated” meaning a specific group of the same staff always work on PEIA’s account. They are not exclusive to only PEIA, but dedicated (designated).

Technical Proposal (page 28): Please confirm the requirement only applies to claims adjudicated in pharmacies domiciled within the state of West Virgina.

a. “Confirm all claims will be adjudicated using the lesser of logic in the system and that the system will survey, at a minimum, the NADAC/WAC (if applicable), AWP discount, U&C, or MAC (if applicable) at retail, and the lesser of AWP discount, or MAC at mail and the NADAC/WAC (if applicable), AWP discount or MAC (if applicable) at specialty.”

The NADAC plus $10.49 applies to all WV domiciled pharmacies and the PBM specialty pharmacy.

The adjudication logic applies to all claims. NADAC/WAC would be applicable if you offer that type of pricing model. If you are not offering a pricing proposal based on NADAC/WAC or other acquisition cost plus model, then the adjudication logic would apply, minus the “(if applicable)” components.

Technical Proposal (page 36): Please provide definition of ‘domicile’ as it relates to “Please confirm you will reimburse West Virginia domiciled pharmacies at

NADAC + $10.49.”

Incumbent PBM and WVPEIA have defined West Virginia domiciled pharmacies using the West Virginia Secretary of State’s website, Business and Licensing page at: https://apps.sos.wv.gov/business/corporations

In the T&C portion of the RFP, please clarify how this section would be applicable to PBM services. Also, please confirm what ‘Award Document’ refers to.

Antitrust: In submitting a bid to, signing a contract with, or accepting an Award Document from any agency of the State of West Virginia, the Vendor agrees to convey, sell, assign, or transfer to the State of West Virginia all rights, title, and interest in and to all causes of action it may now or hereafter acquire under the antitrust laws of the United States and the State of West Virginia for price fixing and/or unreasonable restraints of trade relating to the particular commodities or services purchased or acquired by the State of West Virginia. Such assignment shall be made and become effective at the time the purchasing agency tenders the initial payment to Vendor.

In exhibit 10, there is reference to “collaborators”. For example, under Subcontractors. Can this be defined by WVPEIA?

Subcontractors

The Vendor agrees to provide PEIA with the names of any and/or all subcontractors and/or collaborators who may perform any portion of the Scope of Work on this Agreement and/or who may have access to PEIA member PII/PHI. Further, the Vendor agrees to accept responsibility and liability for the actions, errors, and performance of any subcontractors who perform any portion of the scope of work on this Agreement. The Vendor shall be responsible for ensuring that any and/or all subcontractors and/or collaborators have been made aware of and are in compliance with the terms and conditions of this Agreement and the documents incorporated by reference into this Agreement.

“Award Document” is the letter the successful bidder will receive from the PEIA Pharmacy Director notifying them of the award of the PBM contract.

"A subcontractor is defined as any individual or entity that performs any part of or all of the service(s) outlined in the Scope of Work of the Agreement. Neither PEIA nor HIPAA use the term 'collaborator' with regard to the performance of services and/or the sharing of PII/PHI. PEIA intends that the Vendor, who is required to be a Business Associate of PEIA, shall collaborate with PEIA on the effective management of the PEIA Pharmacy Benefits offering."

In the T&C section 3.8 (copied below), what does the defined term Consultant mean in this context?

Vendor as a Business Associate: Vendor and the WVPEIA agree, as it relates to use and disclosure of PHI, electronic transaction standards and security of electronic PHI under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the Health Information Technology for Electronic and Clinical Health Act (“HITECH”), that the WVPEIA’s Plan is a HIPAA covered entity and that the Vendor is subject to the terms of the State of West Virginia’s Executive Branch Business Associate Agreement (Exhibit 5) along with its corresponding Appendix A (Exhibit 6). Vendor shall perform the required services as an independent Business Associate contractor and not as an “officer, employee, or agent” of PEIA.

Although PEIA reserves the right to evaluate the quality of the service provided by Business Associate Vendor, PEIA will not control the means or manner of the Vendor’s performance. Nothing in this Agreement proscribes or limits Consultant from performing similar services for others.

Consultant should be interpreted to be the same as the vendor who is a Business Associate of PEIA in this section

See Mail Order Requirement on Page 39 pasted below. How does WVPEIA define “materially lower than the market standard?

b. Please confirm WVPEIA will have the right to monitor mail order discounts for non-MAC generics and have the ability to request PBM increase discounts (without penalty to WVPEIA) if discounts are materially lower than the market standard.

1% lower than market standard.

Section 1.6. Bid Formatting states vendor should type or electronically enter the information onto its bid to prevent errors in the evaluation. Is PEIA requesting that bidders respond by providing answers within the full Technical Proposal document itself?

For the technical proposal, if you submit your response in a separate document, you must comply with the formatting of the technical proposal and provide response in an unlocked format.

For the cost proposal, vendors should submit their response using the cost proposal template.

Section 3.17. notes bidder is required to provide a signature on the certification and signature page. Please advise where the certification page is located for the RFP response.

Under Section 3.17, vendor’s signature on the signature page will be sufficient. There is not a requirement for a certification page to also be signed.

Section 3.3.9. requires a litigation bond in the amount of 5% of the annual administrative fees.

• Please clarify if the bond amount is to be based on the pass-through offer or the PMPM offer.

• Please confirm who the litigation bond should be sent to and what the due date is for providing this to PEIA.

o Due to the turnaround time for acquiring the litigation bond hinging on the final pricing developed by bidder, will PEIA allow the litigation bond to be submitted within 15 business days of the bid closing date (similar to the timing noted for the redacted response submission)?

The litigation bond in the amount of 5% should be based on the annual all-inclusive administrative fee for the pass-through offer.

The litigation bond should be included as part of your RFP response to the ARMSRx RFP contacts shown within the RFP.

PEIA will allow the litigation bond to be submitted within 15 business days of the bid closing date.

The General Expectations instructions states bidders are expected to provide both pass-through and PMPM all-inclusive pricing arrangements. Please provide a list of services that are required to be included in the all-inclusive offers from bidders.

Please refer to the administrative fee tab of the cost proposal.

The General Expectations section states that proposers are expected to provide both a Pass-Through, All Inclusive Administrative Services Only (ASO) pricing proposal, AND an All-Inclusive drug PMPM guarantee. Is PEIA’s intent to implement only one offer type, either the Pass-Through offer OR the PMPM offer?

Yes, only one offer type will be selected, but both are required and will be evaluated.

In the Minimum Requirements section, the RFP asks bidder to confirm the client will receive all manufacturer revenue, and that rebates will include all direct and indirect revenue received from pharmaceutical manufacturers, holding companies, or other contracted entities such as GPOs, as well as other potential fees such as administrative fees, inflation protection, marketing, data, educational, etc. Can PEIA modify the requirement to remove “indirect” revenue from the requirement as bidder can only share direct revenue based on PEIA member utilization?

PEIA requires all manufacturer revenue and rebates associated with PEIA member utilization received by PBM should be passed through to PEIA.

The Pass-Through Pricing Template tab in the Cost Proposal requests pass through pricing for retail, mail, and specialty channels.

• Please clarify the request for pass through pricing at bidder’s mail and specialty pharmacies.

• Is PEIA requesting an acquisition cost-based arrangement at mail and specialty?

Note: Currently PBM owned Specialty is NADAC + $10.49.

PEIA is not asking for pass through at bidder’s mail and specialty pharmacy. PEIA is not requesting an acquisition cost-based arrangement at mail or non PBM owned Specialty pharmacies.

Please confirm that the “OPEN SPECIALTY 1-30 DAYS' SUPPLY” section of the Cost Proposal is requesting pricing for retail specialty claims filled at in-network chain pharmacies and independent pharmacies other than those pharmacies excluded beyond the five bordering states to West Virginia.

We are requesting open specialty and preferred specialty (not exclusive) for evaluation. If your organization offers a preferred specialty network option that complies with legislation, that will align with the way it is set-up today. If not, an open specialty network would be required based on the legislative code.

Please confirm if PEIA wants retail specialty guarantees to be included with the non-specialty guarantees.

For the retail network guarantees, please provide whichever is most cost effective for PEIA. For the retail specialty rebate guarantees, they should be the same as specialty rebate guarantees.

The PMPM Pricing Template tab in the Cost Proposal requests a quote based on a formulary that is most closely aligned to PEIA's current formulary with exclusions. Is PEIA open to implementing a narrow formulary arrangement with tighter management and clinical rules that could deliver a lower PMPM arrangement?

Please align with the current formulary in place for consistent evaluation among proposals.

The Pass-Through Pricing Template states, “If pricing is based on NADAC or other source, please provide your AWP equivalent.” Please clarify the intent of the request. Is PEIA requesting an AWP equivalent for the West Virginia domiciled pharmacies that are subject to NADAC pricing?

Per the Pass-Through Pricing Template, WV Domiciled Pharmacies’ and PBM Specialty Pharmacy’s reimbursement is mandated to be NADAC + $10.49. Please provide your AWP equivalent.

For other channels, this would apply if you were offering a NADAC, WAC or other acquisition cost plus pricing model.

The Performance Guarantees section requests System Availability rate of 99%;

please confirm this standard excludes instances of telecommunication failures and scheduled system maintenance periods.

Confirmed

The Audit section requests bidder to confirm their organization will allow the client, ARMSRx, or the client's designated auditor of their choice to perform the PBM audits. Please confirm the audit firm will be mutually agreed upon between PEIA and the PBM.

Confirmed

The Requested Attachments table asks for bidder to provide a template contract with pricing and contract provisions (item 2) and a template contract (item 16).

Please confirm the requested attachments are requesting the same information;

if not, please clarify the difference in the requested files.

The requested attachments are asking for the same. Please provide your template contract with pricing and contract provisions.

Section 1.2. Mandatory Terms states that failure to comply with a mandatory term in the solicitation will result in bid disqualification; however, the Mandatory Requirements table instructions note that if bidder cannot meet a requirement, they should explain their issue in detail and that significant

Bidders will not be disqualified for including explanations where you cannot meet a requirement. Note that these are specific requirements that PEIA is requesting for bidders to be able to deviations may disqualify bidders. Additionally, the rebate/revenue-related requirement notes that if bidder disagrees with the requested term, they should indicate what the client will receive. Please confirm PEIA will accept responses with modifications (e.g., maintaining existing contract definitions and terms) and will not disqualify bidder for including explanations.

comply. Please also note that bidders must meet a minimum acceptable technical score prior to cost proposal evaluation.

Section 1.4.1. Two-Part Submission states that technical proposals must not contain any cost information relating to the project. Please confirm that questions asking for costs (e.g., performance guarantee dollar amounts) can be included in the technical proposal where requested. Please also clarify if narrative responses detailing cost savings and/or ROI can be included in the technical proposal.

Bidders are able to provide PG dollar amounts at risk in the technical proposal. Please include any cost savings and/or ROI for clinical programs in the cost proposal.

For the PMPM portion of the bid would it be possible to have:

o 24 months of membership data broken out by month o Historical Member paid amounts.

o Current net plan paid PMPM with historical invoice rebate amounts

The following Information is provided as an attachment to this Q&A.

o 24 months of membership data broken out by month o Historical Member paid amounts.

For the Pass-Through pricing template, should the AWP implied guarantees be for both WV and non-WV pharmacies combined or just non-WV pharmacies

Both. Please provide the AWP implied discounts for both WV and non-WV pharmacies. Please provide separately if there is a difference.

Is the current Coupon Program, SaveOnSP fee set up as a shared savings Yes, it is currently set up as a shared savings, but we expect bidders to propose your fees for your program.

As we have been going through the RFP, we noticed that there is a stipulation that there can't be any backend support from other vendors that are also bidding on the RFP. If we utilize another vendor for Medicare/Medicaid claims processing, is it correct that requiring this type of support from another Vendor excludes us from participating?

Using another vendor or subcontractor for Medicare/Medicaid claims processing is not a material issue that would preclude a bidder from submitting a bid. However, there are no Medicare/Medicaid claims processing services requested in this RFP.