Department of Administration / Governor
Purchasing Division
515 E. Musser Street, Suite 300 / Jeffrey Haag
Carson City, NV 89701 / Administrator
SUBJECT: / Amendment 1to Request for Proposal 3412
RFP TITLE: / NV Ryan White Pharmacy Benefits Management
DATE OF AMENDMENT: / February 28, 2017
DATE OF RFP RELEASE: / February 13, 2017
OPENING DATE: / March 17, 2017
OPENING TIME: / 2:00 PM
CONTACT: / Gideon Davis, Procurement Staff Member
The following shall be a part of RFP 3412. If a vendor has already returned a proposal and any of the information provided below changes that proposal, please submit the changes along with this amendment. You need not re-submit an entire proposal prior to the opening date and time.
- RFP Section 9.2.3.4 and 9.5.2.2 Regarding Attachment A: Q1.Can the State please confirm where vendors should place Attachment A, Confidentiality and Certification of Indemnification in their proposals? It appears from the instructions in RFP Section 9.2.3.4 and 9.5.2.2 that Attachment A is to be included in two places: in In Part IA, Section IV, State Documents, and then again in Part III, Section II, Financial Information.,
Attachment A, Confidentiality and Certification of Indemnification shall be included in Part IA, Section IV, State Documents.
- RFP Section # 9.1.1. Please confirm that an electronic signature will meet the requirements for all the documents requiring signatures in the RFP?
Electronic signatures within the documents contained on the one (1) CD or flash drive meet the requirements for all documents requiring signatures.
- The RFP does not mention a requirement for the vendor to pay insurance premiums or late enrollment penalties. Please confirm that this activity is not part of the responsibilities of this contract?
Currently Nevada ADAP has a separate contract for PBM services and Health Insurance services. The vendor is only responsible for PBM services.
- The RFP does not mention the need for the vendor to enroll Ryan White clients in health insurance exchange insurers, commercial insurers, or Medicare. Please confirm that these tasks would not be their responsibility of a vendor as part of this contract?,
See Question 3.
- RFP Section 1.1.5. The requirement says ‘all claims history must be converted into the new system’. Best practices would suggest for the vendor to load 1 year of claims history into the claims system, 2 years of claims history into reporting system/tool, and to archive the remaining claims history. Would the Department consider this acceptable, and if not, can the Department please provide how many years of history they require the new vendor to convert?,
OHA would consider this acceptable.
- RFP Section 3.2.1.5. Please provide a brief description of your existing Medication Management services or a definition of Medication Management (for the purposes of this RFP).
Medication Management Services include identification of early refills, duplication of therapy, dose optimization, therapeutic duplication, drug interaction, quantity limits, high dose, drug-inferred diagnosis interactions, drug-gender edits, geriatric/pediatric precautions, compliance with state laws and regulations regarding prescriptions refill eligibility, management of a prior authorization service, fraud and abuse services, provider education, reviewing available medical history where available, focusing on patients at the highest severity of risk for harmful outcome, intervening and/or counseling when appropriate, implementation and maintenance of an online claims processing database that will track and approve medication dispensing claims and provide client-level data to OHA.
- RFP Section 3.3.1.2. There are conflicting requirements in 3.1.2 and 3.3.1.2. In 3.1.2 the Department is asking for a vendor to provide competitive transparent rates from a vendor managed network but in 3.3.1.2, the Department is asking the vendor to utilize current Nevada Medicaid Reimbursement formula.
Nevada Medicaid currently utilizes NADAC + $10.17 dispensing fee (and other variations) as the major component of their reimbursement formula, which is not a market competitive rate.
Since the Department is requiring the vendor to utilize its own network, would the Department consider allowing the vendor to utilize it's own competitively contracted network rates (typically based on AWP)? These rates can be guaranteed to be less than Nevada Medicaid's (in aggregate) while still preserving ample access to medications for your Clients.
Nevada ADAP utilizes Nevada Medicaid Reimbursement formula.
- RFP Section 3.3.1.11. Would the Department please describe or provide an example of a ‘payment error?
Common rejection codes that are received include: Missing Coverage Codes, Filled After Coverage Term, Product Not Covered, Non-Matched Cardholder ID, DUR Reject Error, Missing Rx Origin Code, and Refill Too Soon. All payments that are able to be made are considered valid payments.
- RFP Section 3.3.1.14. Please describe what is meant by ‘pharmacy locator’. Does the Department desire contact info about pharmacies (e.g. address, phone number) for Department use or is this a tool for Clients?
The “Pharmacy Locator” will be used by clients, providers, and OHA. This information will be placed on the website funded by OHA.
- Please provide the program's average monthly membership (number of Clients).
Nevada ADAP currently has 1720 clients enrolled with 945 utilizing the program (311- ADAP, 299- COB, and 335- SPAP/HAX).
- Please provide the programs average monthly paid claims volume.
Nevada ADAP current monthly paid claim average per group is: ADAP 673 claims, COB 600 Claims, and SPAP/HAX 1000 claims.
- RFP Section 3.3.1.14 (F). Please confirm that drug prior authorization services are not required as part of this RFP. If prior authorization services are a component of this RFP, please provide detailed requirements as well as average monthly PA volume.
Currently, Nevada ADAP formulary does not contain any medication requiring prior authorization (PA). The RFP is requesting the vendor to be able to provide PA services if in the future medication(s) are added to the formulary requiring PA.
- RFP Section 3.2.1.1. For disruption/comparison purposes, would the Department please provide a current listing of the program's pharmacy network (including NPI)? If not able to, would the Department please provide the total number of pharmacies in the program's current network?
In Calendar Year 2016, Nevada ADAP Clients had prescriptions filled by 200 pharmacies. Clients living within the State of Nevada do not have a prescribed pharmacy network. Clients with primary insurance may have a pharmacy network and Nevada ADAP cannot override that network. Clients who use Nevada ADAP as their primary medication coverage (i.e. uninsured clients) can utilize any retail pharmacy within the State of Nevada.
- RFP Section 3.3.1.5. Please provide the average monthly volume of claims that must be 'reversed and rebilled'. Also, please provide the average number of pharmacies involved (monthly).
The average monthly volume of reversed claims is 203 reversals per month for an average of 21 pharmacies per month.
- RFP Section 3.2.1.16. Please provide a monthly average breakdown of claims to be 'back billed' by payer type (e.g. Medicaid, Medicare, other).
See Question 14.
- RFP Section 3.3.1.4. Please consider revising to include "except for scheduled downtime". Scheduled downtime is usually performed off-hours and is necessary for the maintenance of the system (upgrades, patches, changes). This is an industry standard practice.
The vendor must ensure that Nevada ADAP clients have access to PBM medication services 24/7 365 days a year.
- RFP Section 3.3.1.3. Please provide additional detail about these retrospective reviews, to ensure vendor comprehension of the requirement. What triggers a review? How is the review information communicated to the Department?
Retrospective reviews are part of Medication Management which would include services for identification of fraud and abuse. The vendor is requested to provide information as part of this RFP as to what would trigger a review in their system and how it would be managed.
- RFP Section 3.3.1.3. On average how many retrospective reviews are done each month?
Current volumes are minimal; this would be dependent upon activity that the vendor may identify as potential for fraud and abuse.
- RFP Section 3.3.1.3. Please describe how medical information will be shared with the vendor, to pair with pharmacy data, in order to conduct these retrospective reviews.
Medical information would not be required to perform reviews for purpose of identification of fraud and abuse.
- RFP Section 3.3.1.3. Please describe what is meant by 'and agreed to by the parties'. What parties and who shepherds this process/agreement?
The parties are the State of Nevada Ryan White Program and the Vendor. The vendor would shepherd the process.
- RFP Section 3.2.1.3. Please describe the current process for electronically transmitting data from the State for patient eligibility.
Currently, a contractor of Ryan White HIV/AIDS Program administers the eligibility screening and enrollment of individuals into the Ryan White ADAP for medication benefits. The contractor adds new individuals and modifies existing individuals’ enrollment dates and ADAP groups (ADAP, COB, and SPAP/HAX) within the Pharmacy Benefits Manager directly. OHA is open to automating the process through a data bridge or other mechanism to improve data quality, reduce staff time in the input, and speed up enrollment.
- RFP Section 3.2.1.3 Will the Department use the industry standard 834 to exchange Client eligibility info? If not, will the Department please provide the current layout for vendor review?
See Question 21.
- RFP Section 3.2.1.1. Please describe the geographical boundaries of your desired pharmacy provider network (e.g. national, statewide only, border states)?,
Currently Nevada ADAP clients’ can utilize any retail pharmacy in the State.
- Is there a defined prescriber network/list that will be provided to the vendor or is any prescriber? (appropriately licensed, etc.) allowed?
Nevada ADAP does not currently have or use a defined prescriber network/list.
25.RFP Section 3.2.1.6. Will the Division of the State of Nevada, Department of Health and Human Services (DHHS) provide the 340b price file to the PBM?
The 340b eligible pharmacy will be providing the 340b price as part of their transmission of prescription. The requirement is for the vendor to accept the price submitted by the pharmacy transmission and not override/insert any other pricing for the prescription. There will not be a 340b file provided to the vendor for purpose of pricing the prescription.
26.RFP Section 3.2.1.9. Please provide clarification on this Technical Information specification. We are not aware that Pharmaceutical Manufacturers pay the 340b program “rebates”, as it is a deep discount program and the discount is achieved via the wholesaler to the pharmacy.
Nevada ADAP currently utilizes the Medicaid Rebate model under the 340b Program. Nevada ADAP currently purchase medication at the Medicaid rate and submit quarterly for 340b Medicaid rebates including the ADAP Crisis Task Force negotiated rate.
27.RFP Section 3.2.1.11. Please provide clarification on this Technical Information specification. Is the requirement to provide data files to be used for TrOOP coordination for the Medicare beneficiaries for the COB under the ADAP (SPAP/HAX) program? What “management” is needed for this program beyond providing the data files?
Yes, the requirement is to provide data files to be used for true out-of pocket (TrOOP) coordination for Medicare beneficiaries under the ADAP (SPAP/HAX) program. The vendor shall coordinate coverage and benefits with Medicare Part D Prescription Drug Plans (PDP) and shall ensure that applicable expenditures are credited toward meeting clients’ TrOOP expenditure requirement.
28.RFP Section 3.2.1.16. Please provide additional clarification. Does this refer to reversing the claim processed to the ADAP program and the pharmacy submitting to the other payer or some other mechanism? What time frame after the initial claim would the back billing be limited to?
The vendor shall develop and maintain a system for recoupment services (i.e. assistance with back-billing insurance such as Medicaid, when coverage was retroactive). Nevada ADAP currently have neither a Medicaid back-billing process in place nor an agreed upon process with Nevada Medicaid. Nevada Medicaid allows for Medicaid retroactive eligibility up to three months, and therefore, claims may need to be back-billed up to three months to account for clients’ Medicaid retroactive eligibility.
29.RFP Section 3.3.1.3. Please provide additional clarification on what is required for and entailed in the reviews. Are the reviews to be conducted by a pharmacist? Approximately how many reviews are needed monthly or annually?
Retrospective reviews are part of the Medication Management service which would include services for identification of fraud and abuse. The vendor is requested to provide information as part of the RFP as to what would trigger a review in their system and how it would be managed.
30.RFP Section 3.3.1.7. Is this referring to the COB Programs? What tasks are included in the oversight?
This is referring to the COB and the SPAP/HAX program. The vendor is task with ensuring Nevada ADAP is the payer of last resort.
31.RFP Section 3.3.1.12. Please clarify if this is this referring to the claim response to the pharmacy, as PBMs do not generate transmissions to pharmacies?
This is in reference to the coordination of benefits for patients with more than one source of payment coverage. If the vendor has received eligibility information identifying the patient as having more than one payment source the vendor is to process the claim through coordination of benefit and transmit that information back to the pharmacy.
32.RFP Section 3.3.1.13. Please clarify if this is this referring to the COB process or what eligibility information would be available to identify clients with insurance outside of the ADAP program?
See Question 21.
33.RFP Section 3.3.1.2. The reimbursement formula as provided in the Nevada Medicaid Provider manual references "DOJ Rate" to be used in the lower of pricing. Is this a required pricing benchmark to be used in lower of pricing? If so, will Nevada provide the location where the DOJ Rate is published?
The State of Nevada ADAP will utilize the Nevada Medicaid algorithm for prescription reimbursement with the exception that the DOJ price will not be part of the consideration for lowest price.
34.RFP Section 4.1.3. requires the selected vendor to be appropriately licensed by the State of Nevada prior to doing business in the State of Nevada. Is the vendor required to be licensed prior to award OR can the vendor obtain the appropriate license after award?
Prospective vendors can wait until receiving a Letter of Intent (LOI) before becoming licensed by the State; however licensure must be completed prior to contract approval.
35.Section 4.1.4 cautions vendors that some services may contain licensing requirement(s). Please provide the services requested in this RFP that require licensing requirements. What requisite licensure is required to deem a vendor as responsive?
For this RFP, the State does not require licensure at time of submittal.
36. What organization is the program's current PBM?
Nevada ADAP current contracted PBM is OptumRx PBM of Maryland, LLC.
37.Section 3.2.1.9 Page 10 of RFP.How many invoices/qtr are sent to manufacturers?
The vendor will be required to invoices every pharmaceutical manufacturer the ADAP program paid a claim too in that quarter. Only one invoice is needed per manufacturer as Nevada ADAP currently has no 340b contracted pharmacy.
38.Do you use a lockbox to receive monies from pharmaceutical companies or are checks delivered to PBM?
Currently, Nevada ADAP invoices and reconciles for 340b Medicaid Rebates. Monies are in most cases direct deposited in others a physical check is received. Nevada ADAP is open to a process that improves data quality, program integrity, and reduces staff time.
39.How much history will you need converted for rebates? (How many years?)
No history will need to be converted for rebates.
40.Are all historic documents stored electronically?
Nevada ADAP historic documents from 2014 to 2016 are stored in CAREWare. See for CAREWare information.
41.Please confirm that the response to PART IB should include the title page and the cross reference document referenced in 9.3.3.2. and no additional information
Part IB, Confidential Technical Proposal should include all confidential technical information (if applicable), with cross references to the appropriate section of Part IA, Technical Proposal. If there is no confidential technical information, Part IB is not required.
ALL ELSE REMAINS THE SAME FOR RFP 3412.
Vendor must sign and return this amendment with proposal submitted.
Vendor Name:Authorized Signature:
Title: / Date:
This document must be submitted in the “State Documents” section/tab of vendors’ technical proposal.
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