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Bet-Zur

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  • 1. PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) Request for Proposal Pharmacy Benefit Management Services RFP 7210 for Public Employees’ Benefit Board (PEBB) Aon Consulting 330 East Kilbourn Avenue Suite 450 Milwaukee, WI 53202
  • 2. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) TABLE OF CONTENTS I. INTRODUCTION .......................................................................................... 3 II. PROPOSAL PROCESS ................................................................................. 8 III. GENERAL INFORMATION ..................................................................... 10 IV. PHARMACY BENEFIT MANAGEMENT QUESTIONNAIRE ................... 12 V. PLAN DESIGN AND FINANCIALS ........................................................... 16 VI. RETAIL NETWORK ................................................................................ 17 VII. MAIL ORDER ........................................................................................ 19 VIII. PROGRAM DESIGN AND ADMINISTRATION ..................................... 21 IX. CLINICAL SERVICES ............................................................................. 28 X. PERFORMANCE OBJECTIVES ........................................................ 33 XI. LEGAL/CONTRACTUAL CONSIDERATIONS ......................................... 35 XII. ACCOUNT MANAGEMENT REFERENCES ........................................... 38 XIII. REQUESTED ATTACHMENTS ............................................................. 39 Appendix 1 ..................................................................................................... 40 Appendix 2 ..................................................................................................... 41 Appendix 3 ..................................................................................................... 45 Appendix 4 ..................................................................................................... 46 PEBB RFP 01/10/2005 Page 2
  • 3. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) I. INTRODUCTION PEBB and Aon Consulting are soliciting proposals from pharmacy benefit management (PBM) firms and other medical vendors to provide a prescription drug program effective January 1, 2006. PEBB is considering several options for both medical and prescription drug services. PEBB is requesting that medical vendors who are responding to the PEBB medical RFP including prescription drugs also respond to the Prescription Drug RFP section. Vendors interested in Pharmacy Benefit Management Services only should complete only the Prescription Drug RFP section. PEBB will make the decision about whether to include prescription drugs with the medical plan(s) or carve them out as a stand-alone program after analyzing the results of the RFPs. Background For over two years PEBB has been working to develop and refine its 2007 strategic Vision for changing the medical delivery system (see cover letter and appendix details relevant to this Rx RFP). For the last six years PEBB has spent considerable time studying and analyzing options for improving prescription drug programming for the state and PEBB members. In 2001 PEBB released an RFP for prescription drug services and requested that vendors consider the implementation of evidence-based formulary with reference pricing. During that RFP evaluation, the Board decided to retain the prescription drug program within the fully insured medical plans that were offered for 2002. In every annual renewal since 2002, PEBB has asked the carriers to assist PEBB in advancing the concept of an evidence-based referenced priced formulary. In particular, PEBB has been interested in utilizing the work that the State of Oregon has done in collaboration with the Oregon Health Sciences University in evaluating the clinical effectiveness of twelve therapeutic drug categories. (For additional detail on State of Oregon Rx work see http://www.ohppr.state.or.us/index.html). During 2004 PEBB has continued its work to further refine its 2007 strategic Vision including additional work specific to Prescription Drugs. PEBB contracted with FACCT to assist PEBB in reviewing the prescription drug work that had been done to date and in developing specific criteria and program recommendations related to the PEBB prescription drug programming for this RFP. (See the Final FACCT Report Part One and Two (Exhibit C in the Appendix) for additional details http://oregon.gov/DAS/PEBB/facct.shtml). During 2004 PEBB also requested that Aon Consulting conduct an analysis on the PEBB prescription drug program that included modeling related to the potential use of an evidence-based referenced priced formulary. Aon also generated a financial review to explore self-funding the prescription drug component of the PEBB program. PEBB RFP 01/10/2005 Page 3
  • 4. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) PEBB Vision for 2007 PEBB envisions a new state of health for its members statewide. Key components of the PEBB program will include: • An innovative delivery system in communities statewide that provides evidence-based medicine to maximize members’ health and utilize dollars wisely; • A focus on improving quality and outcomes not just providing healthcare; • The promotion of consumer education and informed choices; • Appropriate market and consumer incentives that encourage the right care at the right time; • System-wide transparency through explicit, available and understandable reports about costs, outcomes and other useful data; and • Benefits that are affordable to the state and employees. Company Description PEBB has authority to design, purchase and administer prescription drug benefits to 45,606 Oregon State Employees and their dependents, representing 115,304 Oregonians. Over the last two years PEBB has developed and refined a new strategic Vision for PEBB that seeks significant innovative changes in the way healthcare and benefits are provided. PEBB’s mission is “to provide a high quality plan of health and other benefits for state employees at a cost affordable to both employee and employer.” PEBB’s NAICS code is 921190. The location of PEBB’s headquarters: Salem, OR 97301 Compensation Aon Consulting, Inc. is the broker of record for PEBB and receives compensation for our services through commissions. Our fees to prepare these specifications, analyze all proposals, and make recommendations to PEBB will be paid through this commission arrangement. Therefore, include a 0.16% commission in your quote. Contract/Rate Guarantee Period PEBB is interested in developing long-term partnerships and contracts. PEBB plans to enter into an agreement with the selected Vendor(s) effective January 1, 2006, for a three-year contract with a January 1 renewal negotiation on each anniversary date. In order for Vendors' contracts to be renewed for 2007 and 2008, Vendors must satisfactorily perform required services and meet annual PEBB RFP 01/10/2005 Page 4
  • 5. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) PEBB requirements for additional Vision elements. The Vendor must guarantee first contract period rates/fees through December 31, 2006. Thereafter, rates/fees and additional PEBB program requirements will be renewed annually on the contract anniversary date, January 1, if agreed to by both parties. Proposal Objectives PEBB wants to accomplish at least the following objectives with the new Pharmacy Benefit Management plan: ♦ Meet PEBB’s 2007 strategic Vision as described throughout the RFP ♦ Increase use of appropriate generics ♦ Increase member appreciation of evidence-based medicine ♦ Encourage the use of the most effective drug at the best price ♦ Increase member knowledge and understanding about medication effectiveness ♦ Reduce medication errors ♦ Ensure that adherence issues are addressed ♦ Encourage shift towards e-prescribing ♦ Collaborate with PEBB and vendors to measure and report patient outcomes related to Rx ♦ Collaborate with PEBB and vendors to integrate Rx data with primary care providers In addition and in keeping with PEBB’s Vision 2007, the Board has expressed strong interest in benefit designs which favor use of medications based on scientific evidence, and which use reference pricing to encourage selection of the most cost-effective drug. Selection Criteria PEBB is committed to achieving the 2007 PEBB strategic Vision and in offering health care programs, which promote cost-effective and patient-oriented care. See Overview of Procurement Process for details. Quality Section Vendors are required to meet the Vision 2007 Quality minimum criteria listed in the Pharmacy Benefit Management section. Preferences will be given to those vendors who are able to demonstrate the ability to achieve the elements in Vision Quality supporting criteria and contract staging listed in section IV of this proposal. (See FACCT PEBB Report Part One and Two for additional detail). In addition, the following criteria will be used to evaluate the overall proposed Pharmacy Benefit Management program: PEBB RFP 01/10/2005 Page 5
  • 6. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) Network Maintenance and Flexibility ♦ Demonstration of a progressive concurrent Drug Utilization Review (DUR) program, including early identification of contraindications and fraudulent abuse of prescribed drugs ♦ Effective retrospective DUR programs, including physician, patient, and pharmacy profiling ♦ Clinical intervention and substitution programs ♦ Ongoing periodic pharmacy audits ♦ Strong quality management ♦ Excellent access to pharmacies for members ♦ Willingness to recruit and add non-participating pharmacies in areas where access is limited to meet Client's employees' needs. Benefit Provisions ♦ Ability to administer PEBB’s benefit design, including implementation of an evidence-based formulary ♦ Ability to develop an evidence-based referenced priced formulary OR propose an innovative alternative that achieves the desired goals of reference pricing ♦ Ability to assess the effectiveness of PEBB’s benefit program ♦ Maintenance of a formulary based on reasonable cost and quality factors and created by an objective Pharmacy and Therapeutics (P&T) committee ♦ Willingness to work with PEBB to develop a Client-specific formulary as needed. Administrative Services ♦ Centralized member support via a toll-free telephone line an on line services ♦ On-line, real-time claim adjudication ♦ State-of-the-art mail service facilities ♦ Responsive customer service support (integrated for mail and retail) ♦ Bi-lingual member and customer service support ♦ Ability for members to use credit cards or personal checks to purchase mail order prescriptions ♦ Claims administration system with advanced cost management tools ♦ Superior account management staff accustomed to working with large national accounts and public entities ♦ An organized approach to program implementation ♦ A willingness to customize procedures to meet PEBB’s needs ♦ Ability to accept electronic transfer of employee eligibility information ♦ Satisfied clients of similar size and complexity to PEBB ♦ Comprehensive patient and provider education programs that address 2007 Vision criteria. PEBB RFP 01/10/2005 Page 6
  • 7. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) Data Management ♦ Infrastructure that encourages close tracking and monitoring of medication by primary care providers. A management information system which supports PEBB's requirements for database maintenance and management reporting as described in the 2007 strategic Vision ♦ Flexibility to structure reports to meet PEBB’s particular needs ♦ Ability for PEBB to design and generate reports through the web or other electronic media. Risk Management ♦ Financially sound organization ♦ Willingness to hold PEBB harmless from professional liability considerations ♦ A willingness to accept risk through performance agreements targeted to specified claim cost management, operational activities and customer service. Clinical Services ♦ An expansive clinical program offering that includes, but is not limited to, retrospective drug utilization review, prior authorization, physician profiling, and specialty pharmacy case management programs ♦ Ability to integrate medical and prescription claims data to enhance drug utilization review and disease management initiatives ♦ Educational programming offered via a multi-disciplinary approach and incorporating the use of the Internet including online medication lists, pharmacy decision support tools at point of dispensing and alert systems. ♦ A well-established Pharmacy & Therapeutics Committee with experience in pharmacoeconomic considerations and evidence-based criteria for formulary drug inclusions ♦ A formulary structure that retains preferred drugs for the entire plan year with provisions for mid-year additions of new drugs. Financial ♦ Ability to maximize prescription drug savings through discounts and formularies ♦ Competitive Average Wholesale Price (AWP) discounts ♦ Competitive Maximum Allowable Cost (MAC) pricing ♦ Competitive dispensing fees ♦ Formulary rebate sharing ♦ Competitive administrative fees. ♦ Complete disclosure of, and ability to audit financial components including rebates and monies paid by pharmaceutical companies for utilization and trend data ♦ Ability to provide “pass through” pricing on network rates and discounts. PEBB RFP 01/10/2005 Page 7
  • 8. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) II. PROPOSAL PROCESS This is a confidential marketing effort. The RFP questions and spreadsheets should be treated as confidential business documents and may not be shared with outside parties without the prior written approval of Aon Consulting. Do not contact any employee of PEBB or Board members regarding this RFP or the selection process. All questions regarding this proposal should be directed to Mylia Christensen. In addition, technical questions specific to Pharmacy Benefit Management issues should be directed to Connie Perry: Consultant's Name Mylia Christensen Consultant's Title Vice President Address 1211 SW Fifth Avenue Address Suite 750 City, State, Zip Portland, OR 97204 Telephone # 503.306.2865 Fax Phone # 503.228.7447 E-mail Address Mylia_Christensen@aoncons.com OR Consultant's Name Connie Perry, PharmD Consultant's Title Vice President Address 330 East Kilbourn Avenue Address Suite 450 City, State, Zip Milwaukee, WI 53202 Telephone # 414.225.5345 Fax Phone # 414.276.3929 E-mail Address connie_f_perry@aoncons.com PEBB RFP 01/10/2005 Page 8
  • 9. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) Timetable (subject to change by notice) Event Target Date Issue RFP January 10, 2005 Pre-Proposer Conference January 14, 2005 Confirmation to Propose Responses Due January 21, 2005 Deadline for Written Inquiries/Protest of Solicitation Specifications January 21, 2005 Questions Answered by PEBB January 28, 2005 Proposals Due February 25, 2005 Notification of Finalists April 15, 2005 Deadline for Protest of Finalist Selection April 22, 2005 Finalist Interviews/Negotiations Begin April 25, 2005 Notice of Tentative Award June 21, 2005 Award Protest Deadline June 28, 2005 PEBB Issues Letter of Understanding August 1, 2005 Execute Contract (on or before) December 1, 2005 Contract Effective Date January 1, 2006 Finalists selected at the end of the vendor analysis will be asked to participate in vendor interviews. Proposal Format – see Overview of Procurement Process for detail. Inquiries may also be directed to either Mylia Christensen or Connie Perry. All correspondence and questions are to be directed only to Aon Consulting. We ask that your proposal be complete and that it comply with all aspects of these specifications. Any missing information could disqualify your proposal. All costs associated with this proposal are the sole responsibility of your organization. Unless you note to the contrary, we will assume that your proposal conforms to our specifications in every way. Vendor’s Errors/Omissions Neither PEBB nor Aon Consulting will be responsible for errors or omissions made in your proposal. You will be permitted to submit only one proposal. You may not revise or withdraw a submitted proposal after the applicable deadline. After submission, revisions to your original submission will not be allowed except as requested by Aon Consulting or PEBB. Therefore, please take care to make your proposal sound and competitive. PEBB RFP 01/10/2005 Page 9
  • 10. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) III. GENERAL INFORMATION Please provide the following responses about your organization. Provide separate responses for retail and mail service if applicable. 1. Company information: Name Street Address City State Zip Code Web Address Contact for this Proposal Contact E-mail Address Contact Phone Number 2. Please complete the Executive Summary – Label Attachments A1-Organization Overview, A2-Organization Chart, and A3-Terms and Conditions. 3. Briefly describe your company ownership/controlling interest. Include whether a pharmaceutical manufacturer owns your organization, or if you are aligned with one. 4. Please identify any anticipated changes in ownership, including but not limited to mergers, stock issues, and the acquisition of new venture capital. 5. Please list any companies, to which you subcontract services, this includes Specialty Pharmacy services and Mail Order facilities. 6. Please provide the number of pharmacists, pharmacy technicians, member service representatives, account service representatives, and sales representatives employed by your organization. Retail Mail Order Total Pharmacists Pharmacy Technicians Member Service Representatives Account Service Representatives Sales Representatives PEBB RFP 01/10/2005 Page 10
  • 11. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) 7. Please provide the volume of your business for the past three calendar years. 2002 2003 2004 Retail Mail Total 8. If retained, will you provide a copy of your professional liability insurance certificate for this program as described in Exhibit G of the Medical Appendix? 9. If retained, would you provide a copy of your Errors and Omissions policy as requested in Exhibit G of the Medical Appendix? PEBB RFP 01/10/2005 Page 11
  • 12. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) IV. PHARMACY BENEFIT MANAGEMENT QUESTIONNAIRE Please provide the following responses about your organization and its ability to meet the goals of PEBB’s Vision 2007. VISION CRITERIA: QUALITY INDICATORS The following criteria are considered by PEBB to be minimum requirements for future contractors. Questions 1-9 are a pass/fail section. Minimum Criteria 1. Is your organization willing and able to implement an evidence-based drug formulary in 2006? 2. Is your organization willing to work with selected medical vendors to implement an evidence-based formulary in 2006? 3. For 2006, will your organization have the capacity to share formulary information with prescribers in real-time? 4. For 2006, will your organization have the ability to provide regular feedback to providers on their prescribing habits? 5. For 2006, will your organization have the internal capability or be willing to collaborate with third party predictive modeling and case management systems? 6. For 2006, will your organization require new IT acquisitions to conform to Federal Consolidated Health Informatics (CHI) data standards? (http://www.whitehouse.gov/omb/egov/gtob/health_informatics.htm) 7. For 2006, will your organization have email capabilities regarding the prescription drug benefit to members (including access to a complete medication list)? 8. For 2006, is your organization willing to implement a system that provides clinical alert information to pharmacists, prescribers and members? 9. For 2006, will your organization have the capability to integrate prescription drug services with providers through e-prescribing capabilities, including formulary decision support tools at the point of prescribing and computerized prescription order entry systems for prescribers? PEBB RFP 01/10/2005 Page 12
  • 13. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) Supporting Criteria 10. For 2006, please describe all robotic dispensing systems utilized to ensure accuracy of dispensing. 11. For 2006, will your organization use a multi-disciplinary approach to patient care outside of disease management programs? This includes follow-up by pharmacists and nurses regarding drug therapy and adherence issues. 12. For 2006, how does your organization ensure prescribers are notified of any disease management initiatives implemented by your organization? 13. How does your organization ensure secure email exchanges regarding medication histories and personal health information? 14. Is your organization able to support the implementation of an evidence-based reference- priced formulary through education, e-prescribing, pricing and incentives, and feedback systems? 15. Does your organization have a medication adherence program currently in place? 16. Does your organization notify both prescribers and pharmacists regarding drug interactions and allergy information? 17. Do you or any medical carrier or third-party administrator for whom you have a business relationship offer e-prescribing? 18. If yes, which vendors? 19. Does your organization currently have systems to support e-prescribing capabilities including real time formulary information and pricing access in place? 20. Does your organization have the ability to allow members to participate in their own drug selection process (specifically as it relates to cost and benefit of alternative medicines)? 21. Does your organization currently have the capability to import and export pharmacy data to share with providers? 22. Does your organization have on-line capability to share formulary, pricing, and performance data with patients? 23. Has your organization built a pharmaceutical care model such as the Asheville project, in PEBB RFP 01/10/2005 Page 13
  • 14. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) order to better charge community pharmacists with a larger responsibility for care coordination? Please describe. Supporting Documentation 24. Please provide sample screens of your organization’s standards regarding e-prescribing. 25. Please provide sample member introduction or screen shots for patient on-line access to lab results, medication lists, etc. 26. Please provide a detailed description of any medication adherence programs, with results, provided through your organization. 27. Please provide up to three examples of any outcome studies published through your organization last year. The outcome studies should revolve around medication issues such as compliance, dose optimization, prescribing issues, plan design or disease management. 28. Please provide your organization’s reporting mechanism for medication errors. Contract Staging as Appropriate PEBB recognizes that it may take several years to implement all of the elements of the Vision. The Board would like to advance the minimum requirements each plan year to assure that vendors are making significant progress in implementing the Vision elements. Contractors who will be awarded PEBB contracts will be asked to meet new requirements each year based on PEBB experience and continuous learning over the next three years. PEBB reserves the right to revise these for future years’ renewals. Based on PEBB’s current preferences, would your organization be able to achieve the following phase-in schedule? 29. Would your organization be willing and able to implement an evidence-based referenced- priced formulary by 2006? 30. If you are not able to implement an evidence-based formulary with reference pricing, are you willing to propose an alternative to reference pricing that will achieve PEBB’s goals? (If yes, please see Plan Design/Financials Introduction paragraph – Scenario 4.) 31. Would your organization be willing and able to provide a medication adherence program by 2007? 32. For 2007, is your organization willing and able to implement or support an e-prescribing capabilities? PEBB RFP 01/10/2005 Page 14
  • 15. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) 33. For 2007, would your organization be willing to build a pharmaceutical care model such as the Asheville project, in order to assign community pharmacists with a larger responsibility for care coordination? PEBB RFP 01/10/2005 Page 15
  • 16. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) V. PLAN DESIGN AND FINANCIALS As noted previously, PEBB is seeking plan and financial information on several possible scenarios including the following: 1. Retain current PPO and HMO Rx plan design 2. Consider alternative Coinsurance Rx plan design as noted in Appendix 2 3. Evidence-based Referenced Priced Formulary 4. Alternative plan design suggested by the proposer to promote an evidence-based formulary A current census is provided in Appendix 1. Appendix 2 contains the current prescription drug plan design and the financial tables for completion. A claim history has been provided in Appendix 3. Complete Drug Pricing Sheets provided in Appendix 4. For purposes of this proposal assume that a minimum of 45,606 employees plus their dependents will be covered under the managed prescription drug card program. (Additional information regarding PEBB plan and carrier history is located in the Medical RFP section; Current and alternative Rx plan designs detail is located in the Medical/Rx Appendix Exhibit A). 1. Complete the financial exhibit containing pricing, fee and rebate criteria in Appendix 2. 2. Please indicate any additional service items that require an additional charge and indicate the charge and the basis for that fee. Functionality Requested/Capabilities Benchmarks “Yes or “No” responses are elicited in this section. We encourage you to explain the reasons for “No” answers. Explanations should be numbered to match up with the “No” answers in the questionnaire and should be clear and concise. They cannot exceed one page. 3. Your proposal is issued in accordance with the specification and assumptions stated in this Request for Proposal. If there are deviations, please identify them clearly. 4. You can offer complete disclosure and transparency regarding all financial components under the contract, including AWP discount rates under each network provider, MAC pricing, dispensing fees and rebates. 5. All fees, discounts, rebates, and guarantees are auditable by PEBB. PEBB RFP 01/10/2005 Page 16
  • 17. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) VI. RETAIL NETWORK Functionality Requested/Capabilities Benchmarks “Yes or “No” responses are elicited in this section. We encourage you to explain the reasons for “No” answers. Your responses should apply to your current capabilities, or those that will be available by 2006. Explanations should be numbered to match up with the “No” answers in the questionnaire and should be clear and concise. They cannot exceed one page. 1. Please state which version of NCPDP standard you use for submitting claims. 2. All pharmacies are required by contract to submit the lower of current retail price (usual and customary) and your contracted price. 3. All pharmacies are required by contract to actively encourage generic substitution. 4. Network pharmacies must participate even if they do not agree with the reimbursement formula proposed for a specific employer. 5. You will add a pharmacy where access is not adequate. 6. You will perform periodic on-site audits of pharmacies. Information Requested 7. Please provide a copy of the applicable network pharmacy agreement. Label Attachment 1. 8. Provide a copy of your pharmacy credentialing guidelines. Label Attachment 2. 9. Provide a copy of the plan and any materials you use to communicate with network pharmacies about this customer. Label Attachment 3. 10. Please provide geo-access mapping for each of you proposed networks utilizing the following parameters: two network pharmacies within 8 miles. Label Attachment 4. 11. Please provide a copy of your most recent network pharmacy satisfaction survey including the survey questionnaire, documentation of the survey methodology, and the results of survey. Label Attachment 5. 12. Please provide documentation of any pharmacy report card programs available including the data reported, pharmacy performance standards, the results, and any associated costs. Label Attachment 6. PEBB RFP 01/10/2005 Page 17
  • 18. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) Focused Questions 13. In the previous calendar year, what percentage of claims was paid below the contracted AWP? 14. In the previous calendar year, what percentage of total brand name drug costs was saved through discounted AWP pricing? 15. In the previous calendar year, what percentage of total generic drug costs was saved through MAC pricing? 16. What percentage of retail prescriptions was dispensed with generic drugs over each of the last three years? 17. What percentage of retail prescriptions was switched to generics in the past three years? 18. What additional costs are the members responsible for in an out-of-network claim 19. How many generics and what percentage of generics are represented by your MAC list? 20. For generics represented by your MAC list, what is the equivalent AWP discount on average? 21. The MAC list, including MAC pricing, that would be utilized for this account must be included with this proposal. Label Attachment 7. PEBB RFP 01/10/2005 Page 18
  • 19. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) VII. MAIL ORDER Functionality Requested/Capabilities Benchmarks 1. You dispense only “A” rated generic drugs as approved by the FDA and documented in the Orange Book. 2. In the previous calendar year, what percentage of your mail order prescriptions was dispensed and mailed within 48 hours of the prescription’s arrival at the facility? 3. In the previous calendar year, what was your mail order dispensing error rate? Requested Information 4. Please provide a copy of the mail order pharmacy’s policies and procedures as it relates to accepting and dispensing prescriptions and exceptions processes. Label Attachment 8. 5. Please provide copies of all material mailed to members receiving mail order prescriptions. Label Attachment 9. 6. Please provide a copy of your disaster recovery plans that would be use in the event of a facility closure. Label Attachment 10. Focused Questions 7. Is your mail order program JCAHO accredited? What score did the program receive? 8. Describe your organization’s capability to list both member and employer contributions to the overall cost of each medication filled through mail order. 9. What percentage of mail order prescriptions was filled with a generic in each of the last three years? 10. What percentage of mail order prescriptions was switched to generics in the past three years? 11. How many generics and what percentage of generics are represented by your mail order MAC list? 12. Does the MAC list for retail vary against the MAC listing for mail order? 13. The mail order MAC list that would be utilized for this account (unless the same as retail) PEBB RFP 01/10/2005 Page 19
  • 20. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) must be included with this proposal. Label Attachment 11. 14. For the mail order facility that would service our client, provide information including location, monthly dispensing capacity, number, or prescriptions dispensed in the most recent month, ratio of pharmacists to pharmacy technicians, and average number of prescriptions dispensed per pharmacist per hour. 15. What standards do you have for timeliness of filling original and refill mail order prescriptions? Actual Turnaround (In Days) Routine “clean” Prescriptions Prescriptions requiring intervention PEBB RFP 01/10/2005 Page 20
  • 21. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) VIII. PROGRAM DESIGN AND ADMINISTRATION GENERAL Functionality Requested/Capabilities Benchmarks 1. You can offer a 90-day supply of medication at a retail pharmacy using mail order discounts and rebates. 2. In the previous year for your book of business, MAC pricing was what percentage off of AWP? Please quote based on gross cost, not net copays. 3. Your formulary may be customized to the need of PEBB. 4. You provide educational information to members. Please list the program type (i.e., asthma, diabetes, etc.) and the type of educational material (i.e., mailings, internet, etc.) provided. 5. Your registered pharmacists consult directly with prescribing physicians. Information Requested 6. Please list the drugs you recommend be included for prior authorization and the criteria for approval of coverage. Label Attachment 12. 7. Please describe how open, preferred, and closed formularies would operate under your mail and retail programs. Include the criteria for formulary drugs, frequency of formulary updates, and composition of the pharmacy and therapeutics committee. Please include a hard copy and electronic copy of your formulary. Label Attachment 13. 8. Please describe how your organization would work with PEBB to implement a customized evidence-based formulary. Describe and assume a continual interaction between your P&T Committee and key individuals affiliated with the Plan where evaluations of multiple therapeutic drug classes would be completed. Be specific to timing of reviews and evaluation of new medications on the market, price changes, rebate impact, and utilization. 9. Describe how your organization would incorporate the State of Oregon Evidence-Based Prescription Drug Information. Be specific to timing of updates and technology necessary and available. (For additional detail on State of Oregon Rx work, see http://www.ohppr.state.or.us/index.html) PEBB RFP 01/10/2005 Page 21
  • 22. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) 10. Describe how your organization would adjudicate claims based on a reference priced formulary. 11. Please describe your current experience regarding the development of a customized formulary under your book of business (include whether the account is a health plan or employer, etc). 12. Please describe your quality assurance process. Describe how standards have been established. Label Attachment 14. 13. Please describe your therapeutic substitution program including the list of medication and their associated documented savings associated with implementation of your therapeutic substitution program (present as percentage of savings off total drug spend). Label Attachment 15. 14. Description of appeals process that would support PEBB’s intention that employees with unique medical needs would have access to appropriate medication through an appeal process and without additional financial penalties. Focused Questions 15. In the prior year, what percentage of total claim costs was saved though generic substitution? 16. In the prior year, what percentage of retail and mail order-based total claim costs was saved though therapeutic substitution? 17. Is the information that you provide to members about various disease states produced by your organization? 18. What formula do you use to calculate MAC? 19. What percentage of all generic drugs is on the MAC list? 20. How quickly are drugs added to the MAC list after patent expiration? Describe the process for which new generics, under brand exclusivity for 180 days, may be priced on availability to the market. 21. What is your definition of bioequivalency when using generics? 22. Provide your drug mix over the past three years separately for mail and retail. Provide number of single source brands, multi-source brands, and generics. PEBB RFP 01/10/2005 Page 22
  • 23. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) Single Source Multisource Generic Total Retail Mail Order 23. How do you identify and candidates for case management? What is the process for case management after an individual is identified? Is there a fee for case management? REPORTING Functionality Requested/Capabilities Benchmarks “Yes or “No” responses are elicited in this section. We encourage you to explain the reasons for “No” answers. Explanations should be numbered to match up with the “No” answers in the questionnaire and should be clear and concise. They cannot exceed one page. 24. You will provide semi-annual written evaluations of cost and utilization with recommendation for improvement. 25. Your reports include graphics and or visual tools. 26. Your reports include national benchmarks and comparisons to your book of business. 27. Clients can query utilization data from their desktop at no charge. Information Requested 28. Please attach a copy of standard plan experience report(s) that would routinely be provided to PEBB. PEBB requires monthly experience reports be sent to Aon along with claims information. Label Attachment 16. 29. Please describe all ad hoc reporting capabilities available via a consultant, employer, or on- line and any charges associated with these services. 30. Complete the attached tables providing cost and utilization data for specific drugs. See Appendix 4. PEBB RFP 01/10/2005 Page 23
  • 24. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) MEMBER SERVICES Functionality Requested/Capabilities Benchmarks 31. Your organization utilizes the same member service center for both retail and mail order calls. 32. Your member service center is accessible via a toll free number 24 hours a day, 7 days a week and online. If not, please list the hours of the member service center. 33. In the previous year, what percent of member service calls did a representative answer in 20 seconds or less? 34. Your call abandonment rate was what percent? 35. What percent of calls received a busy signal in the prior year? 36. You maintain a dedicated individual or staff responsible for resolving claim disputes or other issues. 37. During the previous year, what percent of new members received their ID cards by their effective date of coverage? 38. Your standard for placing terminations in the system is how many hours after receiving correct information? 39. Does your company provide a member accessible website? Please list all capabilities available as of today on your website. YES (√) Client Specific Formulary Formulary Look-up Tier placement, alternative drugs, generic availability, cost of prescription Client specific copay, limits, exclusions Drug Information Pharmacy Locator Member specific medication profile On-line refill Member Benefit Summary including Employer Amount Paid Other Components Available by 2006: PEBB RFP 01/10/2005 Page 24
  • 25. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) Information Requested 40. Please include a copy of your member satisfaction survey and the results of you most recent company-wide survey. Label Attachment 17. 41. Please include a sample ID card. Label Attachment 18. 42. Please provide a demo ID and pass code to your member website for evaluation by Aon Consulting. Focused Questions 43. How large do you require an employer group be to warrant a dedicated customer service staff? 44. Do you distribute pharmacy directories, or do you request employees call a toll-free number or access your website for pharmacies in their area? ELIGIBILITY Functionality Requested/Capabilities Benchmarks “Yes or “No” responses are elicited in this section. We encourage you to explain the reasons for “No” answers. Explanations should be numbered to match up with the “No” answers in the questionnaire and should be clear and concise. They cannot exceed one page. 45. You can accept other electronic transfer of eligibility (i.e., tape transfer). 46. Your organization has the capability to allow for manual, real-time, online updates to eligibility. 47. You provide a mechanism allowing PEBB to audit eligibility records. Information Requested 48. Explain the procedures a retail network pharmacist would follow (i.e., eligibility verification, copay collection, etc.) if there were a problem accessing the on-line computer system. Label Attachment 19. Focused Questions 49. How are eligibility files transmitted (i.e. FTP, website, etc.)? PEBB RFP 01/10/2005 Page 25
  • 26. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) 50. Will notification of a member’s termination be in your system within 24 hours of notification? 51. What are the normal hours of system availability? CLAIM ADMINISTRATION Functionality Requested/Capabilities Benchmarks “Yes or “No” responses are elicited in this section. We encourage you to explain the reasons for “No” answers. Explanations should be numbered to match up with the “No” answers in the questionnaire and should be clear and concise. They cannot exceed one page. 52. You will provide a monthly data feed of prescription drug claims, in a standard format, to a medical carrier or DSM firm at no charge for the purposes of disease management services. Focused Questions 53. What kind of encryption does your organization use to ensure security? 54. For the previous year, what was the average time required to process a claim from the time it entered the system until the time it was completely adjudicated? 55. Under what circumstances can a pharmacist override the system? 56. Will members using network pharmacies ever need to submit claim forms? If yes please describe process. 57. Does your system require manual intervention at any point during the claim process? 58. What are your criteria for denying claims for early refill and duplicate claims? COMMUNICATIONS Functionality Requested/Capabilities Benchmarks “Yes or “No” responses are elicited in this section. We encourage you to explain the reasons for “No” answers. Explanations should be numbered to match up with the “No” answers in the questionnaire and should be clear and concise. They cannot exceed one page. 59. Member Booklets/certificates will be provided within 60 days of the effective date. PEBB RFP 01/10/2005 Page 26
  • 27. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) 60. Your organization can provide sample SPDs for use by PEBB at no charge including separate SPDs for different lines of benefit (i.e. actives and retirees). Information Requested 60. Please provide samples of all enrollment and communication materials utilized in your program. Also provide the cost of production of these materials if applicable. Label Attachment20. 61. Please provide all data elements and the file format necessary for electronic transmission of eligibility and termination of coverage. Label Attachment 21. PEBB RFP 01/10/2005 Page 27
  • 28. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) IX. CLINICAL SERVICES DRUG UTILIZATION REVIEW Functionality Requested/Capabilities Benchmarks “Yes or “No” responses are elicited in this section. We encourage you to explain the reasons for “No” answers. Explanations should be numbered to match up with the “No” answers in the questionnaire and should be clear and concise. They cannot exceed one page. 1. Your company currently offers a dose optimization program. Information Requested 2. Identify the specific retrospective utilization management programs that you will implement (Label Attachment 22) and provide the following statistics for each program for the most recent calendar quarter (Note: Data should be for your active commercial population only, please specify if otherwise). ♦ Frequency of interventions made as a percentage of all members who utilize the system. ♦ Frequency that a change in utilization is made as a percentage of members identified. ♦ Estimated percentage of total claim costs saved (based on gross cost) as a result of changes. 3. Explain your organization’s savings methodology and calculations for retrospective drug utilization review programs. Focused Questions 4. Please list all concurrent DUR (CDUR) program edits currently available (i.e., drug interactions, drug-gender, etc.). 5. In the previous calendar year, what percentage of total drug costs (based on gross costs) was saved as a result of concurrent DUR (CDUR)? 6. Please list all retrospective DUR (RDUR) program edits currently available (i.e., duration, over utilization, etc.). 7. In the previous calendar year, what percentage of total drug costs (based on gross costs) was saved as a result of retrospective DUR (RDUR)? PEBB RFP 01/10/2005 Page 28
  • 29. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) 8. What is the change rate in drug utilization due to your DUR programs? 9. Can you report on DUR interventions on a regular basis for clients? 10. How often are DUR rules re-evaluated? 11. Provide an example of a DUR for migraine medication including physician letter, clinical information, and rule set. 12. What percentage of CDUR or RDUR rules is generated internally by your clinical department versus standard to the industry? Please give examples of clinical rules developed in-house. 13. Please list all drugs included in your dose optimization program. 14. Is your dose optimization program a standard offering or does a client need to opt into the program? 15. Is there an extra fee for this service? FORMULARY PROCESS 16. Please list all names and describe the background and experience of members currently serving on your P&T Committee. List whether members are compensated by salary, stock, consulting fees, expenses, or an honorarium per meeting, if applicable. 17. Please provide your organization’s administrative practices regarding the review of new drugs, changes in FDA indications, dosages, and use. Be specific to administrative practices where a customized evidence-based formulary is utilized. 18. What is your organization’s administrative practice regarding review and changes made to the formulary list? Be specific to administrative practices where a customized formulary is utilized. 19. How does your organization ensure that the formulary generated is based strictly on available evidence, versus cost and rebates? REBATE INFORMATION 20. How many different drugs do you have rebate contracts for? PEBB RFP 01/10/2005 Page 29
  • 30. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) 21. Provide a list of drug names and manufacturers for the drugs you have rebate arrangements. 22. You will disclose the specific discount by manufacturer upon the benefit contract. 23. Your contract with manufacturers allows for full disclosure of discounts and terms to auditors. 24. Your rebate contracts are available for financial auditing if requested by our client. 25. On what percentage of drugs on your formulary are rebates paid out? 26. When reporting rebate dollars to clients, you will provide the customer with which of the following: reports by manufacturer, product line, NDC, or allowing on-site audits? PRIOR AUTHORIZATION PROCESS Information Requested 27. Describe the appeals process you use in the program. Please include sample provider and patient appeals correspondence. Label Attachment 23. 28. Your organization can support a customized appeals process that may be required with implementation of an evidence-based formulary should this Client pursue. Focused Questions 29. What is the average response time for handling appeals? 30. Describe the savings associated with your prior authorization program if implemented by our client. Provide savings estimates in percentage off total drug spend (gross). SPECIALTY PHARMACY PROGRAM Functionality Requested/Capabilities Benchmarks 31. Does your company have a specialty pharmacy program? Please describe in detail all capabilities and savings to date associated with this program. 32. Is your organization’s specialty pharmacy program JCAHO accredited? What score did the program receive? PEBB RFP 01/10/2005 Page 30
  • 31. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) 33. Is there an extra fee for this service? 34. Is your specialty pharmacy program in-house or outsourced? If it is outsourced, who is the provider? 35. Please describe in detail the process a member would undergo to utilize the specialty pharmacy program. DISEASE MANAGEMENT PROGRAMS /PROVIDER INITIATIVES Currently PEBB provides Disease Management Services (CDM) through a variety of vendors (see Wellness overview in Exhibit F of the Appendix for details). PEBB also reviewed wellness and CDM programming in the FACCT work on the 2007 strategic Vision (see FACCT Report Part One and Two related to wellness and CDM services http://oregon.gov/DAS/PEBB/facct.shtml or Exhibit C of the Appendix). As noted in the report, PEBB is most interested in integrated comprehensive services for PEBB members that includes wellness and disease management services that are integrated into the PEBB member’s medical home. 36. Please describe provider education programs and associated documented savings. 37. List the performance measures covered in physician profiling reports or report cards. 38. Describe any resources used for face-to-face physician intervention (academic detailing). 39. Please provide a representative example of an outreach intervention to providers and its outcomes. Include the methodology for tracking these outcomes. 40. Describe the procedures and mechanisms in place to control patient and pharmacist fraud. 41. Please describe the results of a past initiative where medical claims were merged with pharmacy data to implement disease management. Describe how the integration of medical and pharmacy claims improved patient care. Address drug and medical outcomes, clinical and humanistic outcomes, absenteeism, and productivity issues. 42. How are patient medication noncompliance (adherence) issues addressed? 43. Please state the involvement of the following professionals in disease state management programs for your organization: physician, nurses, pharmacists, case managers, social workers, etc. 44. Disease management programs developed with help from pharmaceutical companies are available to clients at no charge. PEBB RFP 01/10/2005 Page 31
  • 32. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) Information Requested 45. Describe all disease management programs included in your proposal. Be specific as to topic, identification process for member, provider and member intervention, outcome assessment process, number of lives currently enrolled, fees associated, and direct and indirect savings to date with each program. Label Attachment 24. Focused Questions 46. Are your disease management programs designed in-house or outsourced? 47. Are your disease management programs customizable? 48. Do your disease management programs automatically enroll all eligible members or do members opt-in to the programs? 49. Are your disease management programs NCQA/URAC accredited? 50. What is the estimated ROI for your Disease Management programs? 51. Describe how primary care providers are notified of programs and how care is coordinated and integrated? 52. Is there a guarantee on ROI for your Disease Management programs? Be specific as to clinical outcomes guarantees as well as financial guarantees. 53. Is the ROI for disease management auditable? 54. Are savings calculated using gross or net totals? 55. Is there a fee associated with integration of medical data? 56. Is there a fee associated with data extraction or sending data to a medical carrier? PEBB RFP 01/10/2005 Page 32
  • 33. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) X. PERFORMANCE OBJECTIVES Aon Consulting recommends performance measures be included in the contract and be used to manage and evaluate performance. These standards are divided into various categories. Please indicate whether you are willing to implement performance standards with financial penalties for the performance objectives outlined below. For purposes of responding to the RFP, you should assume that PEBB would work jointly with your organization to develop a measurement methodology and agreed upon financial parameters. Be specific as to what financial penalty your organization will place on each measure. Key Measure Description of Measure Best Practice Standard Reporting Frequency Reporting Standards Standard Reports distributed on a Within 45 days of end of Quarterly regular basis. This includes reporting quarterly cycle of core performance measures. Prior Authorization The response timeline for prior 2 business days Quarterly Turnaround Time authorization requests is reasonable Claim Adjudication Prescription claims are processed with 99.9% of claims are Quarterly Accuracy Rate accuracy processed with 100% accuracy Average Speed of Average speed of answer for all calls 100% of calls answered Quarterly Answer received by customer service unit within 25 seconds Mail Service Number of days for mail service 95% of “clean” orders are Quarterly Prescription prescriptions to be delivered to mailed to members within 2 Turnaround Time members business days Mail Service Number of days for mail service 97% of “problem” orders Quarterly Prescription prescriptions to be delivered to are mailed to members Turnaround Time members within seven (7) business days of receipt Call Resolution Rate Calls answered and resolved by 85% of calls are resolved on Quarterly customer service unit first call Denied/ No administrative fees are charged for Vendor agrees with N/A Rejected Claims denied or rejected claims description of measure Drug Use Review Network pharmacies are required to Vendor agrees with Quarterly Tracking review CDUR messaging and take description of measure and action as appropriate. can report pharmacist(s) intervention on a regular basis if required Formulary Updates Benefits Staff or designee(s) are Vendor agrees with Quarterly notified about upcoming product description of measure additions or deletions to the formulary Effectiveness of Measures the effectiveness of vendor in Score on survey which Annually Account Management providing service to PEBB assesses communication, responsiveness, accountability, and overall satisfaction Rebate Check Rebate check is delivered in a timely 60 days post end of TBD by and efficient manner with appropriate reporting quarter PBM documentation of calculation of amount PEBB RFP 01/10/2005 Page 33
  • 34. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) Key Measure Description of Measure Best Practice Standard Reporting Frequency Access to Claims Data Ability for PEBB’s benefits staff and Claims data received Monthly their designee(s) to access claims data, monthly etc. for the purpose of auditing, etc. Mail Dispensing Accuracy rate for dispensed mail 99.995% Accuracy Quarterly Accuracy service prescriptions Paper Claims Turnaround time for processing of 97% within 5 days Quarterly Processing paper submitted claims 100% within 10 days System Downtime Access to system by retail pharmacies 99% access to system Quarterly in network Implementation Measures the satisfaction of PEBB on Score on mutually agreed N/A the implementation process upon survey is satisfactory Generic Substitution Vendor will provide an overall retail 93% Rate Quarterly Rate generic substitution rate based on all multisource products that pay at the generic price, when the physician and state law indicate that therapeutic substitution is appropriate Member Satisfaction PBM will survey PEBB membership to PBM will be at risk should Annually determine program satisfaction rates. less than 90% of respondents surveyed indicate dissatisfaction as defined by both parties Eligibility Eligibility updates provided in a format Loaded within two (2) Quarterly that is mutually acceptable to both business days of receipt parties 100% of the time Claims Experience Claims experience will be provided to Within seven (7) calendar Quarterly any designated third party vendor days after the end of each quarter Complaints Written customer service complaints 100% will be responded to Quarterly will be responded to by PBM within ten (10) business days from receipt Critical Service Issues Timing to address client critical service Within 48 hours of Quarterly issues notification from PEBB, critical service issues should be addressed. If the issue is not resolved within 48 hours of notification, a framework for resolution should be provided. Critical service issues must be resolved within seven (7) business days. PEBB reserves the right to renegotiate any or all performance standards annually. However, the performance standards described in this section will remain in effect unless specifically modified by PEBB. Confirm agreement in your response. PEBB RFP 01/10/2005 Page 34
  • 35. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) XI. LEGAL/CONTRACTUAL CONSIDERATIONS Functionality Requested/Capabilities Benchmarks “Yes or “No” responses are elicited in this section. We encourage you to explain the reasons for “No” answers. Explanations should be numbered to match up with the “No” answers in the questionnaire and should be clear and concise. They cannot exceed one page. It is the intent that PEBB will contract directly with a vendor for all the capabilities described in this RFP. Any capability for which the vendor will be relying upon the service of assistance of a third party must be disclosed. The vendor should describe the nature of such relationships, including a description of all relevant agreements between the two parties. Examples of this would be mail order or utilization review services. In addition to the Legal Terms and Conditions listed in the Medical/Rx Appendix - Exhibit B, the chosen vendor must be willing to include in the agreement the following Hold Harmless language: a) Vendor shall indemnify and hold harmless PEBB, its respective Trustees, employees (acting in the course of their employment, but not as claimants) and agents, for that portion of any liability, settlement and related expense (including the cost of legal defense) which was caused by vendor’s negligence, willful misconduct, criminal misconduct, breach of this Agreement, fraud, or its breach of fiduciary responsibility in the case of an action under ERISA, related to or arising out of this Agreement or PEBB’s role as employer or Plan sponsor. b) PEBB shall indemnify and hold harmless vendor, its affiliates and their respective directors, officers, employees or agents, for that portion of any liability, settlement and related expense (including the cost of legal defense) which was caused solely, directly and independently of all other causes by PEBB’s gross negligence, breach of this Agreement, willful misconduct, criminal misconduct, breach of this Agreement, fraud, or its breach of a fiduciary responsibility in the case of an action under ERISA, related to or arising out of this Agreement or PEBB’s role as employer or Plan sponsor. c) The party seeking indemnification under (a) or (b) above must notify the indemnifying party promptly in writing of any actual or threatened action, suit or proceeding to which it claims such indemnity applies. Failure to promptly so notify the indemnifying party shall be deemed a waiver of the right to seek indemnification. d) The indemnifying party may then take steps to be joined as a party to such proceeding, and the party seeking indemnification shall not oppose any such joinder. Whether or not such joinder takes place, the indemnifying party shall provide the defense with respect to claims to which this indemnity applies and in doing so shall have the right to control the defense and PEBB RFP 01/10/2005 Page 35
  • 36. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) settlement with respect to such claims. e) The party seeking indemnification may assume responsibility for the direction of its own defense at any time, including the right to settle or compromise any claim against it without the consent of the indemnifying party, provided that in doing so it shall be deemed to have waived is right to indemnification except in cases where the indemnifying party has declined and defended against the claim. f) PEBB and vendor agree that neither is responsible for the provision of health care by health care providers, that health care providers are not the agents of either, and that in no event shall indemnity obligations under (a) or (b) above apply to that portion of any liability, settlement and related expense caused by the acts or omissions of health care providers with respect to Plan Participants. g) The indemnification obligations of vendor and PEBB shall terminate upon the expiration of the Agreement except as to any matter concerning which a claim has been asserted by notice to the other party at this time of such expiration or within 365 days after effective date of Agreement termination. 1. You agree to incorporate the hold harmless wording described above into any agreement. 2. You agree to guarantee all fees for 12 months from the plan’s effective date through December 31, 2006. 3. You agree to guarantee all discounts for 12 months from the plan’s effective date through December 31, 2006. 4. You agree to provide 120 days notice of any rate change. 5. You will allow our client to terminate its contract, for any reason with full accounting, on any monthly premium due date, provided such notification is give at least 30 days in advance. 6. In the event of a change in vendors, you agree to administer all runout claims. 7. You agree to transfer to our client, within 30 days of notice of termination, all required retail and mail service data and records necessary to administer the plan without a break in history. 8. You will allow our client to audit claims at any time, including, but not limited to rebates and AWP savings. 9. You agree that there will be no pre-existing condition clause for any employees who enroll PEBB RFP 01/10/2005 Page 36
  • 37. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) in the plan at any time. Information Requested 10. Please provide a copy of your company’s standard contract and agreement. Label Attachment 25. PEBB RFP 01/10/2005 Page 37
  • 38. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) XII. ACCOUNT MANAGEMENT REFERENCES 1. Please provide us the name of the primary contact at your organization, should there be any questions concerning your responses in this proposal. 2. A designated account representative must be assigned to our client that has the responsibility and authority to manage the entire range of services discussed in this RFP. This account representative must be able to directly respond to changes in plan design, changes in claims processing procedures, or general administrative problems identified by out client or Aon Consulting. Please complete the requested information on this individual. Key Accounts and References 3. Please provide the names of the five largest accounts in your current book of business. 4. Please provide three references using your prescription drug retail and mail order program, each having a minimum of 45,000 employees. 5. Please provide one reference being a state government plan. 6. Please complete the information requested on three organizations, having at the time at least 40,000 employees, that ceased doing business with your firm (not due to bankruptcy or merger and acquisition) during the past two years. Information Request 7. Describe the recommended implementation activities for PEBB. Please be detailed and specific about the role of client representatives in this process, the role of your account management staff, the schedule of events and elapsed time, and the communication materials. Label Attachment 26. 8. Provide a copy of your plan for managing the account, including periodic review of cost and utilization and recommendations for plan design changes as well as accessibility of member service representatives for answering inquires from our client’s representatives. Label Attachment 27. 9. Please provide a resume of the account manager that will be assigned to our client, including years of experience. Label Attachment 28. PEBB RFP 01/10/2005 Page 38
  • 39. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) XIII. REQUESTED ATTACHMENTS  Attachment 1 – Network Pharmacy Agreement  Attachment 2 – Pharmacy Credentialing Guidelines  Attachment 3 – Sample Pharmacy Communication Materials  Attachment 4 – GeoAccess Report  Attachment 5 – Pharmacy Satisfaction Survey  Attachment 6 – Pharmacy Report Card  Attachment 7 – Retail MAC List  Attachment 8 – Mail Order Pharmacy Policies and Procedures  Attachment 9 – Sample Member Mail Order Communication  Attachment 10 – Disaster Recovery Plan  Attachment 11 – Mail Order MAC List  Attachment 12 – Prior Authorization Drug List and Criteria for Coverage  Attachment 13 – Formulary  Attachment 14 – Quality Assurance Process  Attachment 15 – Therapeutic Substitution Program and Associated Savings  Attachment 16 – Standard Plan Experience Report  Attachment 17 – Member Satisfaction Survey  Attachment 18 – Sample ID Card  Attachment 19 – Network Pharmacy Procedure for System Downtime  Attachment 20 – Sample Enrollment and Communication Materials  Attachment 21 – Data elements and file format for electronic transfer of eligibility and termination  Attachment 22 – RDUR programs  Attachment 23 – Appeals Process  Attachment 24 – Disease Management Programs  Attachment 25 – Standard Contract and Agreement  Attachment 26 – Implementation Timeline  Attachment 27 – Account Management Plan  Attachment 28 – Account Manager Resume PEBB RFP 01/10/2005 Page 39
  • 40. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) APPENDIX 1 Census Information Attached is the employee census file in Excel (.xls) format. GeoAccess Analysis Specifications Employee Population: Covered employees only Provider Definition: 1) All retail pharmacies in your broad network 2) All retail pharmacies in your preferred or restricted network Access Standards: Two providers within 8 miles Reporting: 1) Access Summary – show top zip codes (cities) by number of EE’s with and without access 2) Access Detail – show number of providers and number of employees in each zip code (cities) not meeting the access standard 3) Access Detail – show number of providers by county, as listed below: a. Baker l. Grant x. Morrow b. Benton m. Harney y. Multnomah c. Clackama n. Hood River z. Polk s o. Jackson aa. Sherman d. Clatsop p. Jefferson bb. Tillamook e. Columbia q. Josephine cc. Umatilla f. Coos r. Klamath dd. Union g. Crook s. Lane ee. Wallowa h. Curry t. Lincoln ff. Wasco i. Deschutes u. Linn gg. Washington j. Douglas v. Malheur hh. Wheeler k. Gilliam w. Marion ii. Yamhill PEBB RFP 01/10/2005 Page 40
  • 41. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) APPENDIX 2 1. Please acknowledge that your organization can administer the following plan design opportunity: Current Plan Design PPO Full-Time Employees Retail and Mail Order Generic Preferred Brand Non-preferred Brand $10 $15 $25 PPO Part-Time/Early Retirees Retail Generic Preferred Brand Non-preferred Brand $10 20% 30% Mail Order Generic Preferred Brand Non-preferred Brand $20 $40 $60 HMO Full-Time Employees Retail and Mail Order Generic Preferred Brand Non-preferred Brand $10 $15 Not Covered HMO Part-Time/Early Retirees Retail Generic Preferred Brand Non-preferred Brand $10 $25 Not Covered Mail Order Generic Preferred Brand Non-preferred Brand $20 $50 Not Covered Public Employees’ Benefit Board (PEBB) is considering modifying the Rx plan design for 2006 1. Please acknowledge that your organization can administer the following plan design opportunity: Potential Plan Design Option I Retail Generic Preferred Brand Non-preferred Brand $10 30% or $30 (greater of) 50% or $50 (greater of) Mail Order Generic Preferred Brand Non-preferred Brand PEBB RFP 01/10/2005 Page 41
  • 42. RFP 7210 PBM Request for Proposal for Public Employees’ Benefit Board (PEBB) (PEBB) $30 30% or $90 (greater of) 50% or $150 (greater of) Retail and Mail Order DAW Member Pays Difference Logic 2. Please acknowledge that your organization can administer the following plan design opportunity: Potential Plan Design Option II – Use of Reference Based Pricing Retail and Mail Order Certain medication classes may be affiliated with reference pricing. The application of the reference- based price would be determined by calculating the average daily dose of the medication considered and comparing that cost to an accepted price for the preferred and evidence-based medication. Members would be charged the standard copay, plus the differential, between the reference-based medication and the actual drug selected (unless the medication price is less than the reference priced product). Reference based medications would be associated with a low flat fee copay, i.e. $10. 3. Please acknowledge that your organization can administer the following plan design opportunity AND provide an estimated savings off drug spend based on both scenarios: Potential Plan Design Option III – Use of Out of Pocket Maximums Retail and Mail Order A. Use of a $150 per prescription maximum. B. Use of a $350 quarterly prescription maximum amount paid by the member. This would apply to both the retail and mail order benefit components. 4. Please describe your organization’s recommendation regarding installing out of pocket maximums. Be specific to both “per Rx” and “quarterly maximums” and include outcome data if available. 5. Please provide this Client with a recommended plan design that optimizes the use of evidence-based medicine, while maintaining an appropriate member contribution structure. Potential Plan Design Option IV – Vendor Recommendation PEBB RFP 01/10/2005 Page 42
  • 43. Financial Exhibit Please provide a separate quote for transparent (pass-through) pricing, if available. Retail Type of Network: Most Limited Broadest Number of Pharmacies Nationwide Brand Discount (AWP Discount) * Dispensing Fee per Script Effective Generic Discount across all generics (MAC, non-MAC, and U&C)** Administrative Fee per paid claim *** % of Rebates Shared with PEBB**** Rebates per paid claim**** % of all generics on MAC list Cost per paper claim processed Mail Order Type of Network: Most Limited Broadest Brand Discount (AWP Discount) * Effective Generic Discount across all generics (MAC, non-MAC, and U&C)** Dispensing Fee per Script Administrative Fee per paid claim *** % of Rebates Shared with PEBB**** Rebates per paid claim**** % of all generics on MAC list Start-up Costs Type of Network: Most Limited Broadest ID Card Production and Delivery (cost per card) One time Installation and Set-up Charge Directory Charges Guarantees Type of Network: Most Limited Broadest AWP Discount (12 months) Dispensing Fees (12 months) Administrative Fees (12 months) Rebate Sharing (12 months) Up Front Deposit (if required) Deposit Amount *Discount percentages must be the guaranteed minimum percentage given to PEBB, net of rebates and U&C. Do not report your book average. Discounts are to be based on NDC-11 pricing (versus NDC-9). **MAC pricing will not be accepted. PLEASE PROVIDE A GUARANTEED MINIMUM PERCENTAGE AWP DISCOUNT FOR ALL GENERICS PROCESSED AT RETAIL AND MAIL ORDER.
  • 44. ***Administrative fees are assumed to include all services outlined in this RFP. Administrative fees must apply to paid claims only. ****Rebate guarantees must be expressed a specific dollar amount per all claims. The specific dollar amount must be the guaranteed minimum amount per all claims in retail and all claims in mail. Do not submit rebates based on formulary brands or rebateable products. These quotes will not be accepted.
  • 45. APPENDIX 3 Claims History See 2002-2004 SPECIAL EXPERIENCE BY COUNTY – KAISER.XLS See 2002-2004 SPECIAL EXPERIENCE BY COUNTY –REGENCE.XLS
  • 46. APPENDIX 4 Drug Pricing Sheet Drug Unit Cost Information as of 02/15/2005 Average Average 100% Retail AWP Paid in NDC-11 Drug Name Strength AWP Paid in AWP Retail Mail Order Network 00149047001 ACTONEL 30 MG 64764030114 ACTOS 30 MG 00088110947 ALLEGRA 180 MG 00088216130 ARAVA 20 MG 00029608012 AUGMENTIN 500 MG-125 MG 00029608612 AUGMENTIN 875 MG-125 MG 00029316013 AVANDIA 8 MG 59627000103 AVONEX 33 MCG 50419052115 BETASERON 0.3 MG 00074258660 BIAXIN FILMTAB 500 MG 00025152031 CELEBREX 100 MG 00456402001 CELEXA 20 MG 00004026001 CELLCEPT 500 MG 00026851351 CIPRO 500 MG 00008083601 EFFEXOR-XR 150 MG 58406042534 ENBREL 25 MG 00173045301 FLONASE 0.05 MG/Actuation 00006093628 FOSAMAX 10 MG GLUCAGON 00002803101 1 MG EMERGENCY KIT 00087607411 GLUCOVANCE 5 MG-500 MG 00002751001 HUMALOG 100 U/ML 00002809001 HUMATROPE 12 MG 00173046002 IMITREX 25 MG 00071015523 LIPITOR 10 MG 00071015623 LIPITOR 20 MG 00300334601 LUPRON DEPOT 22.5 MG 00085119701 NASONEX 0.05 MG/Actuation 00078024815 NEORAL 100 MG 00071080524 NEURONTIN 300 MG 00186502031 NEXIUM 20 MG 00069154068 NORVASC 10 MG 00069153068 NORVASC 5 MG 00029321120 PAXIL 20 MG
  • 47. Average Average 100% Retail AWP Paid in NDC-11 Drug Name Strength AWP Paid in AWP Retail Mail Order Network 00003517805 PRAVACHOL 20 MG 00300304611 PREVACID 30 MG 59676031001 PROCRIT 10000 U/ML 00008084381 PROTONIX 20 MG 00052010730 REMERON 30 MG 57894003001 REMICADE 100 MG 00006011728 SINGULAIR 10 MG 00074401390 TRICOR 160 MG 00006011431 VIOXX 50 MG 00173013555 WELLBUTRIN SR 150 MG 00004025652 XENICAL 120 MG ZITHROMAX 00069306075 250 MG Z-PAK 00006073528 ZOCOR 10 MG 00006074028 ZOCOR 20 MG 00049491041 ZOLOFT 100 MG 00310021125 ZOMIG 5 MG 00173055601 ZYBAN 150 MG 00069551066 ZYRTEC 10 MG
  • 48. Generic Pricing as of 02/15/2005 Product Name Strength Date MAC Price Non-Mac Price Acetaminophen w/Cod 300 mg/30 mg Tablet Albuterol Aerosol 90 mcg/Actuation Allopurinol 100 mg Tablet Alprazolam 0.5 mg Tablet Amitriptyline 25 mg Tablet Amoxicillin 250 mg Tablet Chew Amoxicillin 250 mg/5 ml Suspension Amoxil 250 mg Tablet Chew Amoxil 250 mg/5 ml Suspension Atenolol 100 mg Tablet Bupropion 100 mg Tablet Captopril 25 mg Tablet Carisoprodol 350 mg Tablet Cefaclor 250 mg Capsule Cefaclor 500 mg Capsule Cephalexin 250 mg Capsule Cephalexin 250 mg/5 ml Suspension Cimetidine 300 mg Tablet Clomiphene Citrate 50 mg Tablet Clonazepam 1 mg Tablet Cromolyn Sodium 10 mg/ml Solution Cyclobenzaprine 10 mg Tablet Diazepam 5 mg Tablet Diclofenac Potassium 50 mg Tablet Diltiazem CD or Cartia XT 240 mg Tablet Doxycycline 100 mg Capsule Doxycycline 100 mg Tablet Enalapril 10 mg Tablet Etodolac XL 400 mg Tablet Famotidine 20 mg Tablet Famotidine 40 mg Tablet Fluoxetine 20 mg Capsule Fluvoxamine 50 mg Tablet Furosemide Oral 20 mg Tablet Glipizide 5 mg Tablet Glyburide 5 mg Tablet Hydrochlorothiazide 25 mg Tablet Hydrocodone/APAP 5 mg/500 mg Tablet Product Name Strength Date MAC Price Non-Mac Price Ibuprofen 600 mg Tablet Isosorproposalproposale Mononitrate 60 mg Tablet
  • 49. Ketoconazole 200 mg Tablet Levoxyl Levothyroxine Sodium 0.15 mg Tablet Lisinopril 10 mg Tablet Lisinopril/HCTZ 10mg/12.5mg Tablet Lorazepam 0.5 mg Tablet Meclizine HCI 25 mg Tablet Metformin 500 mg Tablet Methlyphenidate 5 mg Tablet Methlyprednisolone 4 mg Tablet Metoprolol Tartrate 50 mg Tablet Naproxen 375 mg Tablet Naproxen Sodium 275 mg Tablet Nifedipine XL 90 mg Tablet Omeprazole 20 mg Capsule Penicillin VK 250 mg Tablet Prednisone Oral 5 mg Tablet Propoxyphene-N/APAP 65 mg/650 mg Tablet Propranolol HCI 80 mg Tablet Propranolol HCI 120 mg Capsule Ranitidine HCI 150 mg Tablet Tamoxifen Citrate 10 mg Tablet Temazepam 15 mg Capsule Terazosin HCI 5mg Capsule Trazodone HCI 50 mg Tablet Triamterene w/HCTZ 25 mg/50 mg Tablet Trimethoprim/Sulfa Methoxazole 80 mg/400 mg Tablet Trimox 250 mg Capsule Verapamil SR 240 mg Tablet Warfarin Sodium 5 mg Tablet
  • 50. Specialty Drugs as of 02/15/2005 AWP Dispensing Administrative Rebate Condition Product Discount Fee Fee Share Adjunctive Therapy Kytril Zofran Anemia/Renal Aranesp Disorders Epogen Procrit Asthma Xolair Bone Mets Aredia Cancers Proleukin Crohn’s Disease Remicade Dystonia Botox Myobloc Deep Arixtra Vein Thrombosis Fragmin Innohep Lovenox Contraception Depo-Provera Gaucher Disease Cerezyme Growth Genotropin Hormone Humatrope Deficiencies Norditropin Nutropin NutropinAQ Protropin Saizen
  • 51. AWP Dispensing Administrative Rebate Condition Product Discount Fee Fee Share Hemophilia Alphanate Alphanine -SD AutoPlex-T Bebulin Benefix Bioclate Feiba Helixate-FS Hemofil-M Humate-P Hyate-C Koate-HP Kogenate-FS Konyne Monarc-M Monoclate-P Mononine Novoseven Profilnine-SD Proplex-T Recombinate HIV/AIDS Antiretrovirals Protease Inhibitors Transcriptase Reductase Inhibitors HIV Wasting Serostim Hepatitis Infergen Intron-A PEG-Intron Rebetron Roferon Infertility Antagon Gonal-F Fertinex Humagon Repronex Pergonal Profasi Pregnyl AWP Dispensing Administrative Rebate Condition Product Discount Fee Fee Share
  • 52. Migraine DHE Imitrex Multiple Sclerosis Avonex Betaseron Copaxone Rebif Neutropenia Leukine Neupogen Neulasta Osteoarthritis Hyalgan Synvisc Osteoporosis Calcimar Osteocalcin Prostate Cancer Lupron Viadur Zoladex RSV Prevention Respigam Synagis Rheumatoid Arthritis Arava Enbrel Remicade Kineret Hormone Deficiency Depo-Testosterone (Androgen) Delatestryl Depo-Estradiol Rh Incompatibility RhoGAM Severe Diarrhea Sandostatin LAR Sexual Dysfunction Caverject Caverject Papaverine Regitine Thrombocytopenia Neumega Thyroid Thyrogen Cancer Diagnostic Other:

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