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Attachment B2To RFP#17-08-01Request for Proposal – Prescription Benefit Management ServicesCity of Roanoke DOCPROPERTY Issue_Date \@ "MMMM d, yyyy"May 5, 2017 RFP#17-08-01 incorporates a request for Prescription Drug Services. Any proposal for such services shall be submitted in accordance with the requirements of RFP#17-08-01.RFP Issue Date: DOCPROPERTY Issue_Date \@ "MMMM d, yyyy" May 5, 2017RFP Due Date: DOCPROPERTY Due_Date \@ "MMMM d, yyyy" June 2, 2017, 2:00 p.m. Eastern Standard time Proposed Effective Date: DOCPROPERTY Implementation_Date \@ "MMMM d, yyyy" January 1, 2018If requested, selected finalists for Prescription Drug Services may be required to participate in face to face interviews with Wells Fargo Insurance Services USA, Inc. and/or its affiliates (WFI) and City of Roanoke and should be prepared to host a tour of their administrative office and bear any costs related to the tour.It is important to emphasize that a major component of this RFP is the establishment of a fixed dollar per unit fee schedule for generic drugs. If the answers to the following questions are not “Yes”, it is likely the fiscal component of your proposal will not be modeled and/or reported.Section X, question LSection XI, question K City of Roanoke OverviewENROLLMENTContractsMembersPPOApproximately 1,800Approximately 2.900HMOHSABENEFIT OVERVIEW*Retail 30Retail 90MailGeneric$15$45$30Formulary Brand$40$120$80Nonformulary Brand$75$225$150Tier 4 20% up to $200N/A20% up to $400DeductibleMaximum OOP*Represents the current setup. Benefit design is subject to change at any time.CLAIM SUMMARYSee attachment G of RFP 17-08-01SECTION IRFP Terms and ConditionsINFORMATION REQUIREMENTS Offeror must submit complete responses to this RFP.? Each response should provide a clear, concise and complete description of Offeror’s strategy and ability to meet the project requirements outlined in this RFP.? The pricing each Offeror submits must include full unit cost information. Proposals not including specific unit cost data (MAC list, brand pricing) will be considered incomplete . Proposals not including a generic unit cost guarantee will be considered incomplete.An officer or other official of the Offeror's firm who has legal authority to commit the firm to performance of the proposed services must sign the information marked as the "original" information as indicated in Section IV – Administrative Fees.? Offeror’s pricing must be firm as proposed and encompass all costs and expenses, including all supplies for the administration of the program, including all shipping costs to Client but not limited to, all labor (including overtime) and materials required to complete or provide service within the specified time frames, all applicable state, federal and local taxes (including sales and use taxes), and all other costs and expenses required to complete or operate the project.If Offeror proposes the use of subcontractors or skilled trade groups to complete any part of the work, Offeror’s information must include a list which discloses each subcontractors name, address, contact person.? Offeror must also include a complete description of subcontracted work and an explanation of the subcontractor’s qualifications and experience.? Include this information in the next section, "Offeror Information".???????????? PROPOSAL PROCEDURE Point of Contact for Questions - Upon review of this entire document, each Offeror may submit questions you may have regarding this RFP.? All questions are to be submitted in writing, via e-mail to: monica.cole@. Offeror should clearly indicate that questions are related to Prescription Benefit Management Services.Response Format - Offeror is to submit a complete submission with written responses to all questions included. Offeror’s response shall be in hard copy and electronic as indicated in Section 1 . Any supplemental information (marketing materials, brochures, etc.) or "boiler-plate” material is to be submitted as appendices and packaged separately from the body of the response.Note: If an additional section outlining an "innovative approach" to managing prescription benefits is warranted for review, a separate section should be added to Section XVII. This supplement should only outline an approach with scope and function truly external to the scope and function outlined in this information. Incomplete responses may not be considered.SECTION IIOFFEROR INFORMATIONCompany Name___________________________________________________Please list location(s) of the company offices and location of the office servicing the account.Name, address and telephone number(s) of the Offeror’s point of contact for a contract resulting from this RFPPrimary ContactName:Title:Address:City:State:Zip:Telephone #:Fax Phone #:E-mail Address:Secondary ContactName:Title:Address:City:State:Zip:Telephone #:Fax Phone #:E-mail Address:Company background/history, including owners with a share greater than 5%, and why the Offeror is qualified to provide the services described in this RFP.Length of time Offeror has been providing services described in this RFP. Provide a brief description of business focus and growth over past five years ( DOCPROPERTY Past_5_Years \* MERGEFORMAT 2012-2016).Provide resumes for staff to be responsible for performance of:Account managementFinancial reconciliationIT supportClinical pharmacy support (supervisor)Senior executive overseeing accountComplete the following form regarding contracted or rebranded services (if not applicable, please indicate "this service provided internally" on the description line).Claims AdjudicationDescription_________________________________________________________Contracted Provider__________________________________________________Date Service Commenced_____________________________________________Pharmacy Network Administration (Contracting, Payment, etc.)Description_____________________________________________________Contracted Provider__________________________________________________Date Service Commenced_____________________________________________Formulary Design, Content, and CompositionDescription_____________________________________________________Contracted Provider__________________________________________________Date Service Commenced_____________________________________________Formulary Rebate AdministrationDescription_____________________________________________________Contracted Provider__________________________________________________Date Service Commenced_____________________________________________Mail Service PharmacyDescription________________________________________________________Contracted Provider__________________________________________________Date Service Commenced_____________________________________________Can all service guarantees and performance agreements outlined in this RFP (and the subsequent contract) be applied to subcontractors?? If not, please explain.For all subcontractors mentioned above, outline payment methods and assurance that service will remain continuous throughout the contracted period.For all subcontractors mentioned above, provide insurance documentation for services provided via primary vendor.Outline methods of assuring insurance requirements are met and maintained by subcontractor on an ongoing basis.Indicate the number of any outstanding legal actions pending or lawsuits yielding court decision or settled in the past two years against or involving your organization, if any. Explain the nature and current status of the action(s). Can you assure these actions will not disrupt business operations?What is the annual turnover rate of the Offeror staff over the past 12 months?SECTION IIIIMPLEMENTATION PLANProvide a proposed implementation plan and timetable, beginning with the award of business to the effective date of coverage (target August 2017 for the award and DOCPROPERTY Implementation_Date \@ "MMMM d, yyyy" January 1, 2018 for the planned effective date), including:Steps required for implementing the program.Roles played by the Client/Offeror.Loading eligibility data file.Production and distribution of network directories and enrollment materials.Contacts and personnel assigned to each step of the implementation process.What is the minimum amount of time recommended to ensure an accurate and eventless transition into the proposed program?Describe, in detail, previous implementation breakdowns or disappointments and measures your organization took to rectify the situation (you must outline three).Is your organization willing to state (in final contract) that they are carrying out services in a fiduciary manner for members of the company's health plan? If not an unqualified “yes,” please explain.Describe your ability to reprocess historical claims within your claims adjudication system prior to implementation for testing and validation purposes. Will you provide this service at no extra charge?Are there any start-up fees with implementation?? If so, how much are these fees and what do they provide? Is there an additional fee for receipt and programming of custom eligibility files? Is there an additional fee for receipt and programming of claim, prior authorization or open refill transfer files? If so, please provide an estimate.Please provide applicable performance guarantees in Appendix C.Describe the on-site training that your organization is willing to commit to during the transition.Describe the member’s experience related to the mail order open refill transfer (ORT) file onboarding process. How does the first script get filled? Do you (or your mail order vendor) proactively reach out to members during transition? If so, when? Are transferred scripts available to the member on the web site upon initial web site setup and log in?SECTION IVADMINISTRATIVE FEESComplete the following in accordance with the instructions provided. Additionally, please provide administrative fees in Appendix B.Plan Effective Date: DOCPROPERTY Implementation_Date \@ "MMMM d, yyyy" January 1, 2018Basic (per claim) Fee:Per Member per Month (Alternate):Services Included:Production of ID cards for all existing members initially, to new members monthly, including medical claims information. Providing on-line access to formulary lists and provider directories to all existing members with web access and printed formulary guides as neededClaims AdjudicationStandard Systems EditsBasic Formulary ManagementEligibility Verification and MaintenanceMAC Program AdministrationStandard Data Reporting and Online Access For ClientCustomer Service including toll-free telephone accessProvider Management and EducationPatient EducationPrior AuthorizationDUR, both Prospective and ConcurrentMedication ManagementAll the above services should be covered under the fee stated above.? However, some services may be offered as optional or ancillary and be covered by separate add-on feesOutline all additional fees (beyond the administration fee) that will be added to the client’s billing (for step edits, age edits, etc.). State whether these additional fees are optional or integrated into the standard offering of your PBM services. It is very important to represent the actual anticipated administrative fee.Detail all additional fees/charges not covered under basic fees (postage, printings, booklets, startup costs, etc.).? Be sure to list all charges.? We will utilize these fees quoted for inclusion in the executed contract.? Variation from stated fees may eliminate the candidate Offeror.The fees presented in this information are binding during the life of this contract. Any unsolicited changes to these fees or additional fees may be grounds for termination.? Does the Offeror comply with the conditions herein?Are reversals subject to an administrative fee?If a claim is reversed, is the administrative fee for that claim reversed?List any other related services that the Offeror offers that have not been specifically requested in this RFP.? Provide charges and fees for these services.PBM’s routinely sell detailed drug utilization data to outside firms, including database managers, marketing firms, drug manufacturers and others.? Such sales will be prohibited under the contract between the successful Offeror and the Client, unless a specific agreement is made that detail:Data content (i.e., Patient, Prescriber, Pharmacy);The customers to which the data will be sold;Time frame and scope;Compliance with Federal HIPAA Privacy and Security RulesThis restriction will not preclude the successful Offeror from including utilization information in statistical summaries, but use of specific data will be prohibited.The Offeror acknowledges the above and will accept penalty language stipulating as such in the final executed contract.Certification - My signature below certifies that I am an officer of the company and authorized to bind it in accordance with the above fee quotation and compliance with the above statements.Submitted by: _______________________________________Signature Date_______________________________________Printed Name, Title ___________________________________SECTION VCLAIM PROCESSING SERVICEGeneral Claims ProcessingIndicate the claim processing operation and facility that will be utilized in the management of this account.? Is this system owned and operated by your organization? If not, name the company you are proposing to use. What is the relationship between your organization and this company?How are the necessary quality and time requirements for claims processing assured for this subcontractor? (Outline separately for claim systems, billing systems, and reporting systems)With regard to the claim processing operation and facility to be used for this account, provide the following:System DescriptionMainframe or Relational DatabaseYears in OperationLocation(s)Annual Claim VolumeSystem Crashes (Outline each event since DOCPROPERTY System_Crash_Date \@ "MMMM d, yyyy" January 1, 2015)Are you able to guarantee system availability for claims processing and customer access? Please provide applicable guarantees in Appendix C.Provide your system uptime statistics for DOCPROPERTY Uptime_Statistics \* MERGEFORMAT 2014, 2015 and 2016. Please provide applicable guarantees in Appendix C.What are the normal hours of operation of the claim operation, customer service, and mail-order facility?? Include extended or weekend shifts.? What mechanisms can enrollees utilize for emergency requests that fall outside of the normal hours of operation?What national drug database will be utilized for claims processing?? What is your position and strategy for potential changes in the national drug databases?What is the average turn-around time for reimbursement of network pharmacies for claims incurred?Do you provide full, detailed accounting of each claim on your claims reconciliation file (CRF)?? How frequently is it provided? ?Can the format be customized?Provide an outline (1 page maximum) of your disaster recovery plan for claims processing and for computer/communications systems.Can you guarantee a system recovery time in case of disaster? Please provide applicable guarantees in Appendix C.Retail Claims Processing?Describe the retail pharmacy claims payment process from date of receipt to full adjudication of checks to providers.? If the process is different for network and non-network claims, discuss separately.Describe security systems and protocols in place to protect confidential patient records (HIPAA compliance).List your claim processing system's automated claim edits that occur at time of claim submission.Based on the latest available data, what percent of paper claims are processed (check issued) within 10 working days from the date of receipt? Provide statistical report.For the claim office proposed, provide the following for the last two calendar years: (a) Financial accuracy as a percent of total claims dollars paid (include over- and underpayments) and (b) Coding accuracy as a percent of total claims submitted.How do you avoid duplicate payments of the same claim?? If duplicate payments or overpayments are discovered, what are your procedures for recovery of the overpayments or duplicate payments?? What percent of duplicate payments and overpayments are reimbursed or credited?Describe your policy regarding lost/broken medication, early refills, and emergency medication fills.Provide an overview of your methods to assure HIPAA compliance.Mail-Order Claims ProcessingA. Describe the claims processing sequence for mail order claims from date of receipt of prescription to fulfillment to adjudication and payment.B. What form of payment can you accept from the enrollee?C. For purchases made by credit card, can refills be phoned in or submitted via the Internet?D. How many days advance notice must an enrollee provide in order to guarantee that their supply is received before the existing supply is depleted?E. What is the average time in days between receipt of claim and delivery to enrollee (include delivery time)? Are you able to provide a service guarantee?F. Are shipping costs included in the dispensing fee? If not, define the additional cost (include rush order cost, if applicable).The retail MAC pricing schedule will be applied to all mail service generic prescriptions. Please indicate your approval of this to be included as a contract statement.If specific performance standards are not met (solely determined by client’s metrics), may the client select a mail service vendor independent from their PBM relationship?Is the mail service pharmacy (internal or contracted) IIAS certified (100% certified for FSA card transactions)?SECTION VIACCOUNT SERVICEDiscuss how City of Roanoke will be billed for retail network and mail-order programs, and administrative service fees. Will you bill separately for administrative service fees? Please provide a sample of all billing documents.What sales office would handle the general servicing of this account?? Would this office handle both the retail network and mail-order programs?? What are the standard office hours for the sales and service offices?Will dedicated account service representatives be assigned to this account? Attach an organization chart with staff credentials (all contact elements; e.g.…account, clinical, fiscal, mail service).Do account service representatives have on-line access to real-time claim processing information?? Do these representatives have authority to approve and/or override claims?Will the account manager assigned to this account be exclusive or have other accounts to manage (during 5 month transition, long term)?Describe and outline plan for scheduled periodic meetings with City of Roanoke.? What will be the guaranteed time frame and frequency for meeting with City of Roanoke in person if requested?Do you provide online member addition capabilities to City of Roanoke? Describe renewal activities/analysis that are available to the client (e.g., year end review, copay remodel, etc.)SECTION VIIMEMBER SERVICESWill dedicated customer service representatives be assigned to service client members? Will customer service representatives receive client-specific training?Do customer service representatives have on-line access to real-time claim processing information? Do these representatives have authority to approve and/or override claims? Do City of Roanoke employees have the ability to track on-line, real time claims processing information? How many toll-free numbers are available to City of Roanoke and enrollees to handle claims and other member service issues?? Will separate numbers be required for the mail-order program?? What hours (based on Eastern and Pacific Time, USA) are the telephone lines staffed?What languages will be available to members via the toll-free numbers? Provide audited telephone response data for the past two years.? Include time to answer, talk-time, and abandonment rate.? Are telephone performance reports available on-line? Please provide applicable guarantees in Appendix C.Provide methods for member support services for selecting and/or locating network pharmacies? Outline the different mechanisms of support in detail.Describe the member grievance protocols in place.What is the average response time for general questions?? How is this logged and monitored through an automated system? Please provide applicable guarantees in Appendix C.How are plan members notified (phone, written document, other) of the following events?? How will you notify City of Roanoke of these events?? What is the lead time prior to these changes being implemented?? Provide samples of written notifications.Plan ChangeNew Drug Additions/ Formulary ChangesChange in Pharmacy Network PanelDrug RecallSubmit a sample of all forms that would be used in the administration of this plan (e.g. claim form, completed EOB, grievance form, member reimbursement form) that are included in your standard fees.What services are available to members via the Internet? (Provide detail of service, function, value to City of Roanoke).? Are you willing to provide City of Roanoke specific member satisfaction surveys at no charge?? If so, at what frequency, i.e., monthly, quarterly, semi- or annually?SECTION VIIIPHARMACY NETWORKProvide a copy of your current provider directory.? In which states do you contract for less than 95% of the retail pharmacies available? What number and percent of available retail pharmacies (nationally) are in your network?Please outline, with zip code, all pharmacies in the Commonwealth of Virginia that are not contracted for your network.If it is found that a pharmacy currently non-network for your system is essential to the client, please outline the method of enrolling the pharmacy to your network.SECTION IXPHARMACY NETWORK MANAGEMENT AND QUALITY ASSESSMENTDescribe the general credentialing and re-credentialing process and minimum criteria for selecting a network pharmacy.? Include the minimum required malpractice coverage per individual practitioner, or group.? If the process differs by type of pharmacy (i.e., independent vs. chains), indicate and describe separately.? Provide the number of years that a pharmacy contract is effective.Provide the number of participating retail pharmacies that were terminated from the network in past 24 months:Termination RatesNumber of PharmaciesPercent of PharmaciesGeneral ReasonsIf a pharmacy is to be removed or terminated, will City of Roanoke be able to provide input and/or directly contract? Describe your organization’s objectives/efforts with regard to pharmacy relations.? Is there an oversight committee that addresses pharmacy relations issues?? If so, what are the credentials of the staff members that serve on the committee?? What procedures are in place to monitor network provider grievances?Do you currently perform member or provider satisfaction surveys?? Provide a copy of the latest survey results.? Does an outside organization perform the survey?? What percent of members and providers indicated that they were “satisfied or very satisfied” with the overall program?? Describe the reporting you will provide regarding member and provider satisfaction.Summarize the quality assurance programs your organization presently has in place and list the most important actions these programs have taken in the past year to improve performance.Do you track member complaints? If so, list the top five member complaints received over the past year.? What remedies have been put into effect to resolve these complaints?Do you track provider complaints?? If so, list the top five provider complaints received over the past year.? What remedies have been put into effect to resolve these complaints?What are your criteria for auditing network pharmacies?? Describe in detail the claims auditing procedures established by your company (frequency, extent, etc.).? Will you supply a copy of all such reports to City of Roanoke? How do you ensure that the proper price is reimbursed to pharmacy?? If the “lesser of” provision is provided in your contracts, how do you ensure that the enrollee is always getting the lower of retail or the contractual amount?Indicate which of the following factors are included in your on-site audits:Physician Dispense as Written (DAW) useConcurrent DUR interventionPackage Size SubmittedUsual and Customary pricingGeneric DispensingControlled Substance DispensingCompound DispensingDays SupplyReturn to StockClaims CostClaims VolumeRefill RateUnits per ClaimDEA (physician ID) submissionHistorical Audit ResultsDEA Submission AccuracyConcurrent DUR overrideReversal %Describe any circumstances under which you would use the services of an independent claims auditor.How do you capture pharmacy errors?? List the top five reasons for errors (e.g.? wrong dosage).What percent of erroneous or fraudulent payments to pharmacies are discovered through your audit efforts?? Do you return 100% of all monies you recover based on the incurred claim experience?? If not, explain what portion (if any) is returned.What safeguards exist for preventing one group’s experience from being charged to another?What safeguards exist for preventing breaches in patient confidentiality with regard to medical claims information? Please identify your Chief Privacy Officer and summarize their background and experience.How do you assure network pharmacies have adequate stock on hand? For primary claims, do you guarantee that City of Roanoke will be charged the generic price and the plan participant is charged the generic co pay, if generic is out of stock?? How frequently will you perform a market analysis specific to City of Roanoke?If City of Roanoke identifies a pharmacy with questionable claims, what will be your plan of action?SECTION XPRESCRIPTION DRUG REIMBURSEMENTIn Appendix B, provide the brand drug reimbursement formula guaranteed for all plan members in all locations (mail and retail). Please provide this as a % discount off post-settlement AWPs.Outline your reimbursement method relative to the late September 2009 pricing settlement. Specifically, what is the basis (including formula(s)) of determining prices for brand drugs? If an alternative (WAC basis) is required by Client, is this feasible?Please outline any variation of basic reimbursement based on location or pharmacy vendor. Include both retail and mail service ics to include in detail:Any “lesser of” provisions,MAC pricing procedureGuaranteed Brand AWP discountAlternative pricing (MAC or WAC +) or other formsMulti-source discount brand discount from AWPDispensing Fee/RxIncentive Fees/RxNetwork Access Fees Collected by PBMSubmit your proposed generic pricing in an Excel spreadsheet named “Guaranteed Fixed Unit Cost Pricing”. The values for the generic pricing must be the maximum $/unit ingredient cost that the client will be charged for a given billing cycle, excluding U&C claims. This will be part of the final contract. Please include pricing for all generic medications. The final, contractual MAC shall include all generic medications within the drug database to which you subscribe. This pricing must be submitted based upon GPI or GCN.What is your average discount from AWP (retail and mail) for brand medications? What is the overall brand discount from AWP that can be guaranteed (with financial penalty)?What is your source for AWP? What is the name of the database used for MAC?? How often are prices updated? Will you guarantee that the average cost per brand drugs achieve no less than the percentage discounts from AWP? (cumulative AWP discount < guaranteed AWP discount).It is preferred that your organization fully support and promote “$4” prescription programs (“Wal-Mart” programs). List the pharmacies in your networks that have a $4 charge for many generic drugs.? Outline the programs you have implemented that have advocated and increased use of these “$4” programs.Quantify the value of the lesser of provision in terms of percentage of savings above and beyond the contractual discount percentage.With respect to all pricing formulas presented, will you agree to permit an audit of your claim files by City of Roanoke representatives to verify the reimbursement prices established in the contract?Describe how network pharmacies are reimbursed. Your answer should be consistent with the fees provided in the financial section of this RFP.? Include any incentive-based dispensing fees, bonuses, withholds, retroactive capitations, network access fees, etc.Upon completion of vendor contract, a statement guaranteeing that the average price for a generic (drug/strength/form) will not exceed the agreed upon MAC list (barring exceptional circumstances) will be required and included in the final executed contract. Is this acceptable in your vendor contract?What are your means of assuring reasonableness for compounded drug charges?? Outline pricing policy and methods of assuring accurate pricing. Describe clinical criteria utilized to ensure high cost compounds with commercially available alternatives are denied. Is evidence of efficacy required prior to approving a high cost compound claim?Are all dispensing fees reported and billed to the client exactly the same as that adjudicated for the pharmacy at the point of sale?Please outline all dispensing fees, stated as maximum $/Rx that will be billed for any given month (retail/mail, brand/generic).SECTION XIGENERIC DRUG MAXIMUM ALLOWABLE CHARGE (MAC) PROGRAMDescribe your MAC program for generic substitution.? Will City of Roanoke and its members have access to a current MAC listing? If so, describe.Based on your latest data available, what is the effective discount from AWP of your MAC prices? Describe this generic pricing in terms of WAC. Provide the number of generic products for which you have a MAC price. What percentage of all generics dispensed does this represent?Does your MAC price apply to EVERY pharmacy in your network, without exception? If not, please explain in detail. If this MAC does not apply to all pharmacies, what is the rate to pharmacies that are not applicable to this generic MAC listing.Do client’s members always pay the MAC price for applicable generics regardless of the pharmacies' contract (with consideration of “lesser of” logic)?Does your network contract (or with a subcontractor) stipulate that participants always pay the lesser of U&C or the MAC based ingredient cost of the generic Rx plus dispensing fee?Provide the complete generic MAC list in Excel format (including unit price) as of DOCPROPERTY Recent_Data_Date \@ "MMMM d, yyyy"February 28, 2017 in a file named “Guaranteed Fixed Unit Cost Pricing”. As this will be a requirement of future service, failure to provide such greatly reduces the possibility of being awarded this business. This MAC list must include all generic medications in the drug database to which you subscribe. This MAC will be applicable to the business engaged for this client via this RFP and will be incorporated into the final contract. Indicate your acceptance that this MAC will be incorporated and part of the contractual obligations of your service to the client. This pricing must be submitted based upon GPI or GCN.Outline all elements of network access fees collected in any time during DOCPROPERTY Recent_Full_Year \* MERGEFORMAT 2016. Is it possible to have these fees applied to reduce the cost of the actual claim?The generic MAC list must be equally applicable to mail service claims as well as retail. Please indicate your acceptance of this stipulation in the final PBM/client contract.Cost per unit, in excess of the guaranteed MAC generic pricing ($/unit, included in the contract) will be reconciled and paid to the client every month. U&C claims are not counted towards meeting the MAC pricing guarantee. Please acknowledge acceptance of these terms and inclusion in any future contract.Describe the methods by which the MAC list will be improved (for existing generic products) and/or enhanced to include newly available generic products. This is a standard element of the Wells Fargo Pharmacy Consulting program (for clients) and needs to be prospectively established.SECTION XIIREPORTING/DATA FEEDSWhat is your standard reporting cycle for client cost and utilization analysis, which includes subgroup analysis?? Please provide applicable guarantees in Appendix C.What is your standard reporting cycle for written evaluations of cost and utilization, which includes recommendations for improvement? Please provide applicable guarantees in Appendix C.Are customized reports available at the request of City of Roanoke at no cost?? Do you provide clients with a comparison of financial data to your book of business?Do you provide clients with a comparison of financial data to similar clients?Do you provide access to claims experience through PC or internet based software to: ClientConsultant's OfficeIs there access to an ad hoc reporting tool available through PC or internet?? Please outline mechanics of on-line reporting tool(s) and provide examples. Please indicate that if selected, you will agree that there are no additional fees for the tools referenced above.Please provide a set of standard reports and the periodicity that they are received. Electronic/hard copy/both?Provide a sample report containing the following:Paid Claims Summary (Total membership, number of utilizing members, net claims --including breakdown of claims per eligible member, brands, generics, brand with generic, mail order, percent of mail order – ingredient cost, dispensing fees, taxes, total member co-pays, total paid by other plans, total plan cost, and other data as needed) Monthly Excel file preferredDetail Claim Listing (Utilization and ingredient cost by individual enrollee, listing the enrollee name, unique enrollee ID number, date of service, date submitted, drug name, submitted charge, amount paid, member co-payment, plan paid).Monthly or on requestExcel file preferredTop Drug Report (detail of cost and utilization by top drug products, including common usage)MonthlyPDF file preferredHigh amount claimant report (including enrollee name, unique enrollee ID number, number of RX filled, cost, names of drugs). MonthlyExcel or PDF fileFormulary Savings and Rebate report (provide sample). MonthlyExcel or PDF fileClaims paid by therapeutic category showing total number of claims, eligible charges and claim payments for each category. QuarterlyExcel or PDF filePrior authorization detail: received date, approval date, denial date, reason for denial, enrollee ID, and drug name, % of denials and approvals.MonthlyExcel or PDF fileGrievance, complaint and resolution tracking report. MonthlyExcel or PDF FileFrequency distribution in descending order of cost of each Rx, provide report stats for highest, lowest. MonthlyExcel or PDF FileAre each of the reports mentioned above available online to City of Roanoke?Provide a sample of DUR reports you produce and monitor.Describe any other claim/management reports you would be able to supply to City of Roanoke regularly at no additional charge and the frequency with which they could be provided.? Describe any other kinds of management information reports (content and frequency) that are available for an additional charge and their cost.? A reporting structure will be authorized during negotiations of the contract.Outline your file transfer process for complete claims tapes and eligibility, including: Redundancy, Service availability, etc.Do you provide positive acknowledgement that tape transfer and member upload is complete and in place?What is your turn around time for eligibility loads?Please outline your after-hours triage and service capabilities for IT matters.Do you provide electronic invoicing? Please outline.What is the lag time between when the claims are incurred and the data is available?? What day of the month do you provide the previous months’ data?City of Roanoke will be provided a full data file, without any elements deleted, monthly, and for three months subsequent to the termination of the contract. Please indicate your consent to including the above statement in the final contract.Do you provide/have access to a daily claim data feed and/or reporting? Please describe, including data load timing and type of reporting available. Is claim level detail available on a daily basis?Please confirm your ability to send/receive eligibility, claim and/or accumulator files on a daily basis with any medical carrier or TPA. Provide details around any exceptions.SECTION XIIIFORMULARY PROCEDUREPlease provide an electronic copy in Microsoft Word format of your formulary (as of DOCPROPERTY Recent_Data_Date \@ "MMMM d, yyyy" February 28, 2017) and label "Formulary.doc."What is the composition of your formulary committee? How are members of the P&T Committee compensated?Salary (if employees)Company stockConsulting feesExpensesHonorarium per meeting.Are there requirements for disclosure of all manufacturer relations/payments for all members of the formulary committee (including employees)?What is the scheduled meeting frequency for your committee? Are meetings via phone or in person? Provide the minutes of the last four (4) formulary committee meetings.Is formulary rebate contracting an element of the presentation of value assessment for drugs or for therapeutic class?Do you consider your formulary "evidence-based?"If the answer to "G" above is yes, provide, in detail, your method of critical evaluation of research, your method of compilation of studies, and your method of applying statistical analysis in determining whether a medication has value vs. another agent.For each of the medications below, indicate if the drug is on your formulary as of DOCPROPERTY Recent_Data_Date \@ "MMMM d, yyyy" February 28, 2017.EntrestoTekturnaAdvairDexilantIf it is on formulary, provide the detailed clinical documentation (and evidence-based process) of superior value vs. non-formulary brands and vs. generic drugs in the class.Are any legend drugs excluded from your formulary resulting in them not being covered? If so, list drugs and rationale. Can the client elect to include coverage? Can existing utilizers be grandfathered?Will City of Roanoke be allowed to negotiate and execute its own formulary rebate contracts where it is necessary?Will the following be provided at no cost?Drug monographsNational P&T meeting minutesFinancial/rebate modelingTherapeutic Class ReviewsWhat is the process for the introduction of new drugs to the market place? Are the drugs automatically coded covered or non-covered? Is there a process for an expedited review by the P&T?What tools are available to promote formulary compliance and education?? Include frequency of mailings, faxes, telephone interventions [provide samples of letters sent to patients, physicians and pharmacies].? What methods are used to promote use of lower cost drugs or generics?Have you performed outcomes studies related to patients on your formularies?? If so, provide results that address improved quality of care and reduced drug costs.Describe your process for urgent or emergent FDA decisions.Grandfathering is essential for our clients. Please describe the extent of grandfathering (including perpetual copay override) options available to the client when faced with members that are on medications that are now non-formulary. Are there any limits to your ability to perform this grandfathering, including permanent overrides? If so, please describe. Items to potentially be grandfathered include:Formulary copay tier (for medications that are currently on formulary for a given member, but will be non-formulary after transition)Prior authorizationStep therapyQuantity limitsAge editsGender editsPlan exclusionsPlease provide a list of the top three (in terms of dollar volume) non-formulary, non-specialty drugs from your employer book of business for DOCPROPERTY Recent_Full_Quarter \* MERGEFORMAT 2016Q4. Separately, please provide a list of the top three (in terms of dollar volume) non-formulary, specialty drugs from your employer book of business for DOCPROPERTY Recent_Full_Quarter \* MERGEFORMAT 2016Q4.SECTION XIVFORMULARY REBATESWill you disclose specific discounts by manufacturer, by drug upon signing the PBM/client contract?Do your contracts with manufacturers allow for full disclosure of discounts and terms to auditors selected by City of Roanoke?If City of Roanoke requests a rebate guarantee, can your organization provide a rebate guarantee (rebate $ as a % of total ingredient cost)? Are there brand drugs on your formulary for which no rebates are given but are included because they are clinically superior to other options?? Please outline if so.On what percentage of drugs in your formulary are rebates paid?On what percentage of brand-name drugs in your formulary are rebates paid?How will you provide City of Roanoke with information that verifies rebate monies have been accurately credited by:Reporting by manufacturerReporting by product lineReporting by NDCNet Therapeutic CostProvide a list of drug names and manufacturers for the drugs that you have a rebate agreement for in = DOCPROPERTY Recent_Full_Year \* MERGEFORMAT 2016 + 1 2017. If City of Roanoke were to begin with you on DOCPROPERTY Implementation_Date \@ "MMMM d, yyyy" January 1, 2018, in which month of the same year would the first rebate check be received? Are you willing to pay rebates on a different cycle if requested by City of Roanoke?Describe the method in which formulary rebates are remitted [i.e., check, credit on future invoice].? How often are rebates calculated and paid? Indicate the average number of days between Rx fill date and actual rebate credits/payment.Are rebate eligible drugs on your formulary bundled? ?Explain.Can City of Roanoke eliminate a particular drug from formulary and not have it affect rebates for other drug products?How many independent, direct pharmaceutical rebate contracts can City of Roanoke negotiate, execute, and manage throughout the contracted period? ?What (if any) limitations exist? Provide samples of rebate reports City of Roanoke will receive.? Please include sample reports to be provided to self-funded clients. Please confirm your ability to provide rebate reporting at the sub-group level (e.g., by benefit type or location).Will you provide summary rebate data in Excel or text file format including incurred quarter, paid month, amount invoiced to manufacturer, amount received from manufacturer and amount distributed to client? The successful Offeror must disclose fully its economic relationships with all drug manufacturers to City of Roanoke.? This will include all such revenue sources, both direct and indirect, including but not limited to drug spend rebates and manufacturer administrative fees. Please acknowledge that this is acceptable.Will you accept a penalty fee for noncompliance with the above (Q)?What is the guaranteed yield for rebates in terms of $/brand RXs and % of $ ingredient cost? Are there requirements for this guarantee (be specific). In Appendix B, please complete the table with rebate guarantee as a per brand Rx, separately for retail, mail, and specialty drug.Please acknowledge your ability to grandfather copay status on existing claims (now non-formulary).Formulary rebates, if guaranteed per quarter, must be paid by the end of the 2nd month after the end of the given quarter. 10% interest per month will be collected for each month not paid within this time frame. Please acknowledge your acceptance of this.SECTION XVCLINICAL PROGRAMSDo you provide emergency access to a registered pharmacist 24 hours a day?Do you have a 24 hour service to respond to member’s benefit or therapeutic question?Do you provide free educational information to members with (please describe)AllergyAsthmaCardiovascularCongestive Heart FailureDepressionDiabetesHypertensionPain ManagementSmoking Cessation.Do you provide free educational information to members about:Adverse Drug EventsMedication Safety and StoragePoison ControlChild SafetyDo your registered pharmacists consult directly with prescribing physicians?Will you disclose all manufacturer funding and rebates earned to support clinical programs?Do you allow full client review and approval of all clinical programs affecting members in any manner?Do you allow City of Roanoke full review and approval of all provider and member mailings prior to distribution?? Will this stipulation be allowed under service guarantee (with penalty)?Can you assure City of Roanoke that their prescription claim data will not be distributed or sold to any outside party in any fashion, under financial penalty?Provide detailed description (with measurable results) of your top 3 clinical programs available to City of Roanoke at no charge.Provide methods and programs (with specific processes and criteria) to minimize use of specialty drugs for diseases for which there is no FDA indication and/or evidence based value.Please describe your physician and member education efforts to maximize use of generic diabetic medications and minimize brand diabetic drug use.In what manner are specialty drug criteria utilized for prior authorization more stringent than guidelines based on FDA approval?Describe your method for controlling the use of Glumetza.Describe your method for controlling the use of topical anesthetics (particularly ones that are replicates of OTC products and are very high priced)..Describe your methods to minimize use of the drug product, Entresto, using evidence-based process and synthesis for data analysis.Describe in detail your method for excluding non-FDA approved and unique compounded products (e.g., Lidovex, Pennsaid).The following language will be included in the contract. Please confirm your agreement with this language. “No utilization management (exclusions, step therapy, prior authorization, quantity edits, age edits, gender edits, etc.) will be made without at least six months notice and prior approval of the client.”SECTION XVIDRUG UTILIZATION REVIEW (DUR)What items are included in your standard automated editing process, for soft and hard edits?? Are edits based upon severity levels?? Are the edits available for view online? Complete the following table separately for pharmacy network and mail-order (if applicable):Describe the role of each of the following in your DUR programDUR Edit CriteriaEligible EnrolleeEligible DrugContract Price DrugDrug InteractionsDuplicatePrescriptionEarly RefillMin/Max dailyDuplicate IngredientDrug to PriorAdverse Reaction/AllergyGender EditsQuantity LimitationsAge EditsDrug to GeriatricProper Days SupplyGeneric AvailabilityPatient CopaymentsOther (List)Which of these edits occur prospectively at point of sale, concurrently, and retroactively?Describe your Medication Management program.Does it involve a geriatric pharmacist? Describe his/her qualifications and role.Does it evaluate the full range of a member’s medication regimen, including prescription and non-prescription medications and vitamin and mineral supplements?Does it evaluate the effectiveness and safety of drugs used, dosage issues, drug interactions, duplication, use of brand vs. generic, and side effects?Does it include a component that involves the prescribing physician(s) when opportunities to improve the drug regimen are identified?? Does it include physician education?What criteria are used to identify and monitor high cost claimants?Describe prior-authorization protocols available to City of Roanoke. Outline all clinical/quality of care programs (related to MTM) which will be applied and managed for the client at no cost.Please outline all costs associated with DUR programs, both standard and voluntary. Please include a comprehensive fee schedule for all services.SECTION XVIIUNIQUE STRATEGIESPlease use this section to propose or outline unique strategies you may have for this client. Being very mobile, the employees will benefit from central pharmaceutical care management services. Please submit information in this section only if the strategy is truly unique, as opposed to an enhanced service (i.e., clinical management).There is no requirement to submit such. If not, please state, “none submitted” under this heading.SECTION XVIIIAUDITSDescribe your 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.Describe how the audit department is staffed, including the credentials of the staff.What percentage of pharmacies receive Desk Audits?What percentage of pharmacies receive on-site audits?What parameters trigger a desk audit?What elements are reviewed during the desk audits?What criteria discovered in a desk audit will result in an on-site audit?For on-site audits:Who conducts the audits?What records are reviewed?Describe your methodology for record duplication and handling.How do you control ‘short-counts’ (i.e., fraudulent under-dispensing)?How are partially filled prescriptions and under-stocked drugs addressed?How do you assure that prescriptions not picked up are reversed in a timely manner?Describe your policy with respect to audit recoveries. How are these recoveries shared with City of Roanoke?Describe your process for assuring that network providers respond to your DUR on-line messages.Describe any education provided to network providers following an audit to correct problems from recurring.? Is there scheduled follow-up to ensure the corrections continue?The contract will not allow for services which the client pays for to occur unless the charges are pre-authorized by the client. Is this acceptable as contract language?SECTION XIXSPECIALTY DRUG PRICING AND MANAGEMENTIn what manner is the proposal presented modified if there is complete carve out of specialty drug distribution to a separate, contracted vendor? Please be specific, addressing all adjudication, pricing, and service issues. If there is no impact on the proposal, please state such.Describe your method of interacting with physicians for assessment and authorization of a specialty drug.How is your specialty drug distribution integrated with the clinical/prior authorization department of the PBM?Complete the following form (include all levels of PA/control, including appeals)Types of Specialty Drug Clinical ActivityName of ActivityAction TakenWho Performs?Criteria Utilized (source)ChargeFeel free to expand the size of table as much as necessaryDescribe any innovative means that your organization utilizes to minimize the cost of specialty drugs for clients and their members.For the following drugs, please provide an outline of procedures (including who conducts them) and policies that will occur when a new claim for the given drug is submitted for adjudication (provide pathway including appeal of rejected claim):GleevecSovaldiTysabriThiolaDo any of the rebate contracts utilized by your company (or contracted rebate vendor) limit the extent and ability of your organization to prior authorize and/or deny utilization of a medication when it is deemed not meeting criteria?Specialty pricing must be provided and guaranteed at the drug level. AWP discount pricing and guarantees at the aggregate level likely will result in the proposal not being considered. Please submit specialty pricing in Appendix E with your RFP response. Please add any specialty products on your specialty list that have not been included in Appendix E, if any.Describe how new specialty drugs will be priced and the ability of the client to dispute and/or negotiate new specialty drug pricing.Appendix A - Client Relations1.? Top Five Clients FormInstructions to Offerors: Complete the following chart, listing your top 5 clients/groups starting with the largest number of covered lives. Please include at least 3 employers. ?Include current phone number and address for contact persons.?Client/GroupNumberofEnrolleesInitial Offer DateContact NameAddressTelephone Number123452.? Terminated Contracts FormInstructions to Offerors: Complete the chart below, listing the 5 largest groups that have terminated their contracts with your plan since DOCPROPERTY TermedContracts_Date \@ "MMMM d, yyyy" December 31, 2015. Please include at least 2 employers. Include current phone number and address for cooperative contact persons.?Client/GroupNumberofEnrolleesInitial Offer DateContact NameAddressTelephone Number123453.? Complaints/legal action/debarmentOutline, in detail, any past or pending legal actions/complaints from current or former clients (include all legal actions, court settled or otherwise, since DOCPROPERTY LegalActions_Year \* MERGEFORMAT 2012).Each Offeror is required to state if it has ever been debarred, fined, had a contract terminated, or found not to be a responsible bidder or Offeror by any federal, state, or local government, and/or private entity. If so, please give the details of each such matter and include this information with the proposal response.Appendix B – Financial SummaryInstructions to Offerors: Please provide guaranteed amounts in the table below. A standard MAC list (as described in the PRESCRIPTION DRUG REIMBURSEMENT section of this RFP ) will apply to all generic claims for all pharmacies (dictated by specific contractual language), unless the U&C is lower (or a store “discount” program, a la “Wal-Mart”).Please indicate whether generics are guaranteed based on AWP or fixed unit cost. If both are checked, please verify an offer using both methods being submitted. FORMCHECKBOX Generics guaranteed based on AWP FORMCHECKBOX Generics guaranteed based on fixed unit cost (MAC list)ImplementationAdditional fees not included in the administrative fee or elsewhere$Implementation credit$Administrative FeesBasic (per claim) fee$PEPM (alternate) fee$Prescription Drug ReimbursementRetailRetail 90MailSpecialty VendorBrand MedicationsAWP Discount%%%%Dispensing Fee/Rx$$$$Generic MedicationsAWP DiscountMACMACMACMACDispensing Fee/Rx$$$$Specialty MedicationsAWP DiscountAttach drug level list in Appendix EDispensing Fee/Rx$$$$RebatesRetailRetail 90MailSpecialtyRebate/Brand Rx$$$$Appendix C – Performance GuaranteesInstructions to Offerors: Provide performance guarantees and financial penalties specific to this client. Performance guarantees may be provided below or in a separate document named “Appendix C – Performance Guarantees”. At a minimum, guarantees for the following must be included:Implementation tasks, including time frames, benefit coding accuracy, web site setup and client satisfactionStandard customer service call center metrics, including time to answer, talk-time, abandonment rate and first call resolutionRetail pharmacy dispensing accuracyMail pharmacy, including dispensing accuracy and turnaround time for clean scripts and scripts requiring interventionSpecialty pharmacy, including dispensing accuracy and turnaround time for clean scripts and scripts requiring interventionClaim processing system, including availability and recovery timeReporting, including standard reporting and plan setup recommendations/annual reviewClient satisfaction surveys related to customer service/account managementMember satisfaction surveysAccount management response time for standard and critical itemsPost-implementation tasks, including eligibility load timing and benefit coding accuracyWhat is the frequency and timing of performance guarantee reporting and reconciliation?What is the timing of payment for any amounts due to the client?What is the total amount that will be placed at risk for the client?All guarantees, including those in Appendix B, must stand on their own. No offsetting of guarantees with results from other guarantees is permitted. Please confirm your acceptance of this requirement.Appendix D – Summary of Key Issues1. All claims will be billed to City of Roanoke in the exact amount that is paid to the pharmacy at the point of sale. _____ Yes??????????????????????? _____ NoShort explanation of “No”_______________________________________2. Our company (PBM) is guaranteeing that the maximum cost per unit for any given generic drug will be the value submitted on the MAC list (Section XI, Item H). This value will apply to all generic claims for all pharmacies (enforced by specific, guaranteed contractual language). U&C claims and unique programs, such as, but not limited to “Wal-Mart $4 programs,” will not be considered in determining adherence to the guarantee._____ Yes?????????????????? _____ NoShort explanation of “No”_______________________________________3. All formulary rebates will be completely accounted for (not necessarily 100% distributed), including administrative fees and other funds from manufacturers.?????_______Yes_______No Short explanation of “No”_______________________________________4. City of Roanoke is allowed to independently contract, directly, with its own specialty pharmacy vendor.? _____ Yes??? ??????????? _____ NoShort explanation of “No”_______________________________________5. Formulary rebate guarantee in terms of $/brand Rx._________________________6. Grandfathering is essential for our client. Please acknowledge grandfathering will be supported for all aspects of the benefit (formulary copay overrides, prior authorization, step edits, quantity limits, age edits, gender edits), as described in Section XIII, item Q._______Yes_______No Short explanation of “No”_______________________________________7. Upon termination of the relationship with the client, all necessary data will be provided to the new PBM free of charge. This includes 12 months of historical claim data with sufficient information to successfully make the transfer (including member information, copay and formulary indicator), associated accumulator information (if applicable), prior authorization file with all PAs active after the implementation date, mail order ORT, and specialty ORT. Each file shall be provided three times; once for testing purposes early in the implementation process, once for production data and once for lag data post-implementation._______Yes_______No Short explanation of “No”_______________________________________8. PBM agrees to work directly with any carrier/TPA, free of charge, to ensure all ACA data requirements are met, including combined medical and Rx accumulators._______Yes_______No Short explanation of “No”_______________________________________9. Please confirm PBM agrees to meet with Wells Fargo Pharmacy Consulting quarterly to negotiate additional improvements in the generic unit cost list. _______Yes_______No Short explanation of “No”_______________________________________Certified as accurate ______________________________Title___________________________________________Dated___________________________ ................
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