The Vendor is required to provide pharmacy benefits managers (PBMS) on its existing prescription drug plan for its employees and retirees.
- Disaster recovery plans:
• Claims processing
• Mail service pharmacies
• Specialty pharmacies
• Operations and systems sites
• Offsite storage of all claim history, eligibility, plan design
• Call center support for members, pharmacies, physicians.
- Confirm that members will be using the same toll free number for issues related to retail, mail service, specialty pharmacy, prior authorization, plan design, appeals and claim reimbursement support.
- Provide the number of call centers operated and the locations and hours of operation of each.
- Member website
• Eligibility look up and verification
• Claims history
• EOB
• Formulary information and listings
• Plan design/copays/DED/MOOP, including the ability to price a medication at retail, mail, and specialty
• Pharmacy locator function and access to pharmacy directory
• Mail service/specialty refill ordering and order status checking
• Access to live customer service and pharmacists for questions and clinical support
• Id cards
• Mail service order forms
• Claim reimbursement forms
• Drug price lookup including lower cost and/or OTC options
• Prior authorization documentation
• Appeal documentation and request submissions.
- Provide locations and biographies on the members of the proposed account management team.
- Confirm your standard pharmacy network contains at least 60,000 participating pharmacies.
- All chains are in the pharmacy network being proposed for the city.
- Provide the numbers and reasons for removal from network.
- Provide the number of participating pharmacies in your 90-day retail network.
- Confirm that you are compliant with all state laws regarding maximum allowable cost (mac) reimbursements and pricing transparency.
- Mail service program
• Mail service pharmacies and all clinical staff meet all federal and state licensing requirements.
• Authorize a short-term retail supply at no cost to member or to the plan for any urgent prescriptions needed as a result of a mail service error or delay in shipping on your part.
• Protocol and processes to hold mail service refill requests which are sent before the eligible refill date and whether they process and ship at the eligible refill date.
• Split orders that include both standard maintenance medications and specialty medications and maintenance medications are filled through the mail service pharmacy and the specialty medications are filled through the specialty pharmacy.
- Contract Period/Term: 1 year