The vendor is required to provide one (1) proven pharmacy benefit manager (PBM) service, that can successfully software interface and application program interface (API) with the current contracted pharmacy benefit manager provider system.
- The contractor will deliver administrative and pharmaceutical claims adjudication services, coordination of benefits, and point-of-sale processing services to eligible clients, which include at least the following services:
• Maintain and expand a statewide comprehensive pharmacy network and claims adjudication system inclusive of coordinating multiple contract pharmacies located throughout the state.
• Deliver and manage the Ryan white aids drug assistance program (ADAP) eligibility electronic application and re-certification process
• Facilitate coordination of benefits with payers, including medicare part d and private insurance as covered by the health insurance continuation program (HICP)
• Facilitate and manage true out-of-pocket (troop) cost tracking according to the centers of medicare and Medicaid services (CMS) supplement drug program data sharing agreement (DSA)
• Facilitate the ADAP rebate process and reporting mechanisms.
• Deliver and manage a 340b compliant inventory management system
• Deliver reporting that meets client level data requirements of state ADAP and the Ryan white HIV and aids treatment extension act of 2009
• Ensure that ADAP is the payer of last resort by ensuring there are no other 3rd party payers
- Retail management system
• Maintain and expand a statewide comprehensive pharmacy network that will be available to dispense covered drugs on behalf of the department in the various geographical areas where the ADAP eligible clients are located.
• Deliver and manage an electronic claims adjudication process and direct payment to pharmacies of client share costs such as co-pays, deductibles, and coinsurances on formulary prescription medications for all state ADAP sponsored plans and submit invoices for these costs to the state for reimbursement without markup or fees.
• Deliver and manage a process for adjudicating claims electronically and verifying eligibility at point of service to ensure that dispensing only occurs for patients eligible for ADAP sponsoring plans.
• Maintain the ability to process and transmit claims according to the most up to date national council for prescription drug program (NCPDP) standards as they are promulgated and the most up to date NCPDP format
• In creating the statewide pharmacy network, contractor must enter into agreements with department approved pharmacies and deliver technical assistance to ensure that the participating pharmacy has the capability to process electronic claims for state ADAP clients through the contractor in the most up to date NCPDP format.
• Activate pharmacy providers in the contractor’s system within forty-eight (48) hours of notification from department.
• Deliver and manage a daily on-line pharmaceutical replenishment system with department contracted pharmacies that ensures medication shipment the next business day (24 hours) to department contract pharmacies.
• Deliver and manage a daily on-line 340b compliant electronic inventory management system that tracks a perpetual inventory balance per claims transaction for each participating pharmacy and allows department the ability to verify pharmacy adjudication claims, reconcile medication inventory balances with all orders (electronic and manual) generated for replenishment, invoiced by the wholesaler and shipped to the pharmacy, and supply department with real time access to the system.
• Deliver and manage an on-line retail 340b compliant pharmaceutical replenishment system with department contracted drug wholesaler including partial bottles, full bottles, backordered and discontinued products that reconcile with approved pharmacy claims.
• Department will not incur any charge for access to the adjudication system.
• Provide access to an established pharmacy network approved by department with a point of service system for coordination of benefits for medicare part-d and other health insurance (OHI) claims adjudication.
• Develop and implement an emergency response/preparedness plan that delivers operations of the contracted pharmacy network back to 95% within 48 hours of the conclusion of the emergency.
• Terminate a department pharmacy provider from transmitting electronic claims as soon as possible of notification by department, but no later than 24 hours
• Supply on-line access to current drug information, disease, and health conditions to department pharmacy providers.
• Provide notification to department pharmacy providers of ADAP client’s recertification status at 60 day and 30-day intervals before recertification date.
• Deliver and maintain reconciliation of department true- up formula to department contract pharmacies in accordance with the designated true-up schedule approved by department.
- Clinical services/utilization management
• Provide prior authorization of targeted drugs or targeted management programs at point of service as specified and approved by department.
• Provide prior authorization to identify restricted medications.
• Provide profile analysis and management of network pharmacy performance for six (6) months to one (1) year.
• Provide prior approval process for resolving inappropriate antiretroviral regimens, (e.g., contacting pharmacy and or the medical provider), and facilitating documentation of intervention or resolution.
• Provide technical assistance and 340b compliance training to contract pharmacies in the pharmacy provider network to ensure that the program is being administered appropriately
• Perform random and target pharmacy desk audits at least quarterly.
• Perform targeted dosage and duration of therapy limits at the point of service.
• Provide on-line concurrent drug utilization review (dur) interventions and alerts designed to identify and manage therapeutically appropriate drug and drug regimens and deliver electronic messaging and soft and hard halts to all enrolled department pharmacy providers.
• Department prohibits the contractor from submitting and collecting 340b drug rebate claims and supplemental rebates negotiated by ADAP crisis task force on behalf of department.
• Develop and manage compliance programs designed to identify and manage under-utilization of prescription therapy, including but not limited to antiretroviral therapies and deliver a weekly electronic report to department.
• Electronically approve medication prior authorizations within 24 hours to 48 hours of receiving the request for prior authorization.
• Deliver real-time access to daily electronic inventory reports confirming the closed loop EDI process that electronically receives communication from the department wholesaler verifying product ordered, shipped, received, not received, and manufacturer discontinuation.
• Provide clinical and utilization management programs with educational and monitoring tools for these programs that are offered to clients.
- Program utilization and performance reporting
• Generate electronic automated custom reports and ad hoc reporting per department request without additional administrative charge.
• Supply requested data for audits, and grants within the timeframes requested by department.
• Deliver an electronic process and reporting mechanism to prevent 340b diversion and duplicate discounts for all department pharmacy providers.
- Claims and administration
• Electronically adjudicate claims without a cost placed in the “drug cost” field. for example, drug cost $0.00 for non-insured ADAP claims.
• Deliver an electronic process to transmit primary and/or secondary insurance information to the pharmacy.
• Track and report state ADAP medicare part-d co-payments and client share costs, including troop required under state ADAP eligibility standards.
- Claims administration
• Electronic identify all payer sources, (e.g., primary, secondary, and tertiary payers and supply reporting to department upon request.
• Adjudication of claims without a cost placed in the “drug cost field” (i.e., drug cost $0.00).
• Electronically adjudicate prescription claims and verify eligibility at point of service for all ADAP sponsored plans.
• Electronically prohibit suspended claims from adjudicating as approved claims at point of service.
- Not-Mandatory Virtual Attendance Optional Conference Date: May 21, 2025
- Questions/Inquires Deadline: May 27, 2025