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R -- Pharmacy Benefits Manager (PBM) for World Trade Center Health Program (WTCHP) - RFI

Notice Date
Notice Type
Sources Sought
524291 — Claims Adjusting
Contracting Office
Department of Health and Human Services, Centers for Disease Control and Prevention, Procurement and Grants Office (Atlanta), 2920 Brandywine Road, Room 3000, Atlanta, Georgia, 30341-4146
ZIP Code
Solicitation Number
Archive Date
Point of Contact
Lauren Peel, Phone: 7704882649
E-Mail Address
Small Business Set-Aside
RFI Word Document A. SYNOPSIS This is a request for information. It is not a solicitation for proposals, proposal abstracts, or quotations. Release of this information should not be construed as a commitment to procure items discussed or to incur costs for which reimbursement would be required or sought. The purpose of this notice is to identify: 1) Potential Pharmacy Benefits Manager (PBM) pricing structures to increase transparency as well as control and reduce costs for the World Trade Center (WTC) Health Program; 2) PBM services for administering and operationalizing the WTC Health Program pharmacy benefits; and 3) Potential clinical benefits that PBMs may be able to provide to help improve cost saving measures and formulary management. B. BACKGROUND On January 2, 2011, the President signed into law the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act). The Act established with the Department of Health and Human Services a program to be known as the World Trade Center Health Program (WTC Health Program). The WTC Health Program provides medical monitoring, screening and treatment for responders and survivors of the 9/11 terrorist attacks. Responders include a worker or volunteer who provided services in the aftermath of the September 11, 2001, attacks on the World Trade Center. Survivors include persons that worked, lived, or attended school, childcare, or adult day care in the New York City disaster area, who were adversely affected by the September 11, 2001, terrorist attacks in New York City. As of December 31, 2018, there are a total of 74,107 responders and 18,921 survivors enrolled in the Program. In order to enroll in the Program, survivors and responders must meet certain criteria described in the Zadroga Act. The WTC Health Program is a limited benefit program, meaning that treatment is only covered for health condition for which exposure to airborne toxins, hazards, or any other adverse conditions resulting from the September 11, 2001, terrorist attacks. There is a list of applicable WTC-related health conditions that must be diagnosed by a WTCHP provider, and certified by the Program in order for the member to receive treatment. In order to qualify for treatment, an enrolled member must meet certain exposure, latency, and symptom onset requirements for conditions. A range of conditions are covered including mental health, aero-digestive, and cancer. There are currently seven (7) Clinical Centers of Excellence in the NYC metro area, and one Nationwide Provider Network that administer the benefits to Members. The complex limited structure of the Program poses a unique challenge when managing a members pharmacy benefits. The Program must ensure that drugs are not being covered for conditions not related to the WTC Health Program, while also not impeding access beyond appropriate limits. C. CURRENT PBM SERVICES The current Pharmacy Benefits Manager (PBM) specializes in worker's compensation benefits, and the pharmacy benefits are operationally administered in a way that is similar to worker's compensation. The PBM is responsible for adjudicating pharmacy claims, implementing the pharmacy formulary and point of sale edits, and providing customer service to stakeholders. They also provide and manage the retail pharmacy network, which must be abundant in all 50 states and US territories, as well as a home delivery/mail-order and specialty drug pharmacy. In 2018, the WTC Health Program pharmacy claims expenditures were $97,380,692.29 with 388,104 total claims and 24,624 members utilizing pharmacy benefits. There is significant home delivery use within the program with home delivery penetration at 37.11% in 2018. The PBM provides an external pharmacy adjudication web portal that shows prescriptions processed in real time and routes point of sale edits to the appropriate party, such as the CCE/NPN staff, PBM clinical or customer service team, or CDC. The Program works closely with the PBM to manage operations and processes related to pharmacy benefits and adjudication rules. The PBM also provides some clinical staff to consult on formulary decisions and prior authorizations. The PBM also provides a pharmacy claims data system that allows stakeholders to run a variety of reports on pharmacy claims for quality assurance purposes including data analysis for clinical reviews, cost analysis, program and formulary decisions. In addition, the PBM provides quality assurance and fraud, waste, and abuse reports monthly, quarterly, and ad hoc. These include recommendations for cost savings. PBM staff provide general support to the WTC Health Program for clinical, operational, and customer service projects and daily requests. The PBM is also responsible for all customer service related to pharmacy for both members, pharmacies, and CCE/NPN clinical staff. Additionally, the PBM is responsible for distribution of pharmacy cards, and other types of communications developed in conjunction with the WTC Health Program. D. WTC HEALTH PROGRAM INTERACTION ROLE AND RESPONSIBILITIES The WTC Health Program oversees all pharmacy operations and develops pharmacy program policies. The Program leads a Pharmacy and Therapeutics Forum quarterly where clinical decisions are presented to stakeholders regarding drug coverage and coverage changes. This is done with the support of the PBM. This process includes implementation of policy changes such as communication to Members. The Program also manages multiple contractors that impact pharmacy. Standard Operating Procedures for pharmacy benefits are also developed by the Program and PBM. Member issues, when escalated, are brought to the Program for resolution. The WTC Health Program conducts and overseas all quality assurance activities related to prescription processing, customer service, and other types of processes. For additional information please consult the World Trade Center Health Program Administrative Manual. E. REQUESTED INFORMATION 1. Please describe how your company would propose operationalizing a limited health benefit by ensuring members are only able to receive medications appropriate for their certified condition through the Program. 2. What types of clinical expertise, formulary management, and formulary cost savings resources could your company provide? 3. Please describe your point of sale edit systems and prior authorization procedures. If changes are made to the formulary, are there limitations in how this would be implemented in the system (ex: If a PA is removed off a drug, do prescriptions that previously had a PA still require a PA to process?). 4. What types of contracted price rates does your company utilize? How can your company increase transparency in the cost of medications and reduce prescription costs for the WTC Health Program? a. Do you have pricing alternatives to using Average Wholesale Price (AWP), such as pass through pricing or FSS pricing etc.? b. How are your pricing structures used for all services, including, but not limited to, processing medications, IT system modifications needed by the Program, customer service/call centers, printing and mailing of member communications, web updates for a home delivery portal, generating reports, and other services required of a PBM outside of managing the formulary and providing medications? c. Can you provide a recommended pricing set-up for a federal PBM contract? 5. Please describe your data systems and reporting capabilities on drug utilization and cost projections. Do you have a data system for external users to access? 6. Does your PBM offer home delivery, specialty, or other types of services for pharmacy? Is there a cost incentive to these services? 7. Do your systems allow you to process coordination of benefit (COB) claims, whereby the member's primary insurance is billed first, and the WTC Health Program could be billed secondary at the point of sale? a. Does your PBM offer other services to facilitate coordination of benefits for those patients that do have primary insurance on record? b. Can your systems store and/or block an individual sale when a primary insurance was used in a prior transaction but not used in a subsequent transaction for a member? 8. What type of customer service support does your PBM offer for members, pharmacies, and physicians? (Ex: 24 hour customer service line, dedicated team, etc.) 9. Would your PBM provide communication services, such as development and mailing of pharmacy cards, and other types of member communications? 10. Have you performed similar services in the past for government or other entities? Please provide a list and brief description. Please included contract numbers for federal government past performance, if applicable. F. INSTRUCTIONS 1. Questions about the RFI are requested by 1 PM EST on October 18, 2019, via email to Lauren Peel at ijt9@cdc.gov. 2. Interested parties are requested to respond to this RFI with a white paper. White papers are due by 1PM on November 12, 2019, to Lauren Peel at ijt9@cdc.gov. White papers should list each question identified above and provide the accompanying response below. 3. Interested parties may provide a general corporate capabilities statement in addition to your white paper. Please do not submit a capabilities statement without an accompanying white paper. Capabilities statements should be limited to two (2) pages. 4. Section 1 of the white paper shall provide administrative information, including: a. Company Name, mailing address, phone number, and name and contact information of designated point of contact; b. DUNS; c. Business type (small, large, 8(a), women-owned, etc.); d. Relevant NAICS code; and e. Participation in a GSA Schedule or other government-wide vehicle that may be applicable for this requirement.
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