Pharmacy Benefits Manager Services

The Vendor is required to provide pharmacy benefits manager (PBM) capable of delivering high-quality, employee-centered service while supporting the municipality’s commitment to responsible financial management.
- Requirement:
1. Discount definitions
•    Mac generics included in the generic guarantee.
•    Non-mac generics included in the generic guarantee.
•    Single-source generics included in the generic guarantee.
•    Multi-source generics included in the generic guarantee.
•    Generics in the FDA-granted exclusivity period included in the generic guarantee.
•    Generics launched at risk included in the generic guarantee.
•    Generics prescribed in conjunction with a specialty medication included in the generic guarantee.
•    Generics with limited supply included in the generic guarantee.
•    Claims filled in all states.
•    Limited distribution medications are those defined as such on the bidders provided LDD list with this response.
•    Limited distribution discounts apply for drugs with and without access
2. Rebate definitions
•    Formulary rebates included in the pass-through rebate definition. 
•    Incentive rebates included in the pass-through rebate definition. 
•    Data fees included in the pass-through rebate definition. 
•    Inflation protection rebates included in the pass-through rebate definition. 
•    Specialty management fees included in the pass-through rebate definition. 
•    Market share rebates included in the pass-through rebate definition. 
•    Promotional grants included in the pass-through rebate definition. 
•    Compliance funding included in the pass-through rebate definition. 
•    Any and all funding sources, up to and including those of any GPO with common ownership included in the pass-through rebate definition. 
•    New-to-market drugs, not listed on the LDD list and added during the contract year, must be available from 3 or fewer pharmacies. 
•    For rebates, all drugs on the bidder's specialty drug list qualify for specialty rebate (if not, please list drug classes considered non specialty.) 
•    340b claims are defined as only those having a type 20 NCPDP submission clarification code or a pharmacy class code of 39. 
•    Provided rebate guarantees will apply regardless of plan design.
3. Guarantee and reconciliation logic
•    Bidder agrees to allow the client or a third-party named by the client to execute a market-check.
•    Bidder agrees to pay 100% of any shortfall.
•    Discount guarantees are at the client level.
•    Rebate guarantees are at the client level.
•    Over-performance in one channel will not be used to offset under-performance in another channel.
•    Reconciliations do not constitute an audit.
•    Client may conduct an audit, at its own expense, each year.
•    AWP is based on MEDI-span and the date of fill.
•    AWP is based on post-2009 settlement AWP.
•    U&C is defined based on the retail drug used to calculate the claim amount on the dispense date.
•    Zero balance claims included in discount guarantees based on ingredient cost before member cost share.
•    Extended day supply and mail order guarantees apply at greater than 83 days’ supply.
•    Reconciliation will occur within 180 days after the close of a year.
•    Manufacturer coupons are excluded from the discount guarantee calculation.
•    Bidder agrees formulary list will not have negative changes more than 2 times per year with 90 days advance notice.
•    Specialty list will not change during the contract year with the exception of the addition of new to market drugs.
•    For reconciliation purposes, specialty drugs are defined in the current specialty drug list each contract year. 
•    The PBM may provide an updated list prior to the New Year.
•    All responses in this RFP are binding and super cede the pricing supplement and any administrative agreements.
•    Rebate guarantee reconciliation will not include any rebate credits for shifts in utilization
•    Specialty discount guarantees represents an overall guarantee across all specialty drugs in the channel.
4. Data sharing
•    Share a complete claim file to ringmaster, at no charge, at a minimum of a monthly basis during the administration of this contract.
•    Agrees to share its limited distribution drug list at an NDC level for request and reconciliation purposes.
•    Confirms it has active clients with accumulator connectivity with the current and alternative carriers and TPAs listed in the cover sheet.
•    Active clients with eligibility connectivity with the current and alternative carriers and TPAs listed in the cover sheet.
5. Mail order pharmacy
•    Mac pricing will be in place at mail order.
•    Mail mac is the same or more favorable than the retail mac list.
•    No minimum price floors apply for mail order discounts to apply.