PBM RFP Process
PBM RFP Process
As part of the application process, Troy Medicare will have to contract with a PBM. Here is the criteria in the Request For Proposal:
RFP Objectives
Troy Health is seeking a transparent PBM that will provide high quality service to the plan, participating pharmacies, and its covered members. Critical goals for the organization include:
• Adjudicating claims based on NADAC and maintaining transparent pricing terms for all parties.
• Creating a pharmacy network that meets all requirements and network adequacy rules, and that includes independent community pharmacies in the preferred network (and does not collect any Direct or Indirect Remuneration from those pharmacies).
• Implementing a fairly open formulary, with customization options.
• Placing an emphasis on transparency, adherence, quality clinical outcomes, and competitive administrative fees.
• Providing additional payments to select groups of pharmacies based on their ability to meet clinical targets or provide additional care management services.
Troy Health is seeking pass-through (transparent) pricing proposals that align with their objectives and Medicare pricing requirements. Each bidding PBM should submit proposals describing their network contracting approach, including details such as whether networks are split into preferred and standard pharmacies, as well as any details behind the ability or inability to contract with pharmacies based on NADAC. PBMs may provide more than one network option for consideration.
General Pharmacy Benefit Plan Design and Information
Troy Health plans to offer benefits in three counties within North Carolina during 2020: Cabarrus County, Mecklenburg County, and Rowan. The organization intends to offer Part D benefits with a $0 copay on tier 1 generics, less than $10 copay on tier 2 generics, and tier 1 and tier 2 drugs excluded from the deductible. The Part D plans will not provide mail order coverage. Bidding PBMs should indicate if there are any plan design requirements or other conditions that accompany proposal terms.
PBM Selection Criteria
Troy Health is interested in a formulary that is relatively open. Troy Health will consider formularies that include items such as step therapy, prior authorization, ancillary penalties (i.e. the penalty paid by the member for a brand drug when a generic is available), compounds, and customization options. PBM must list both specialty and non-specialty medications on the formulary.
Troy Health considers the following criteria to be especially critical, although not listed in order of importance, in selecting a PBM to provide and administer their pharmacy benefits:
• Ability to provide an effective network of pharmacies that are predominantly reimbursed using NADAC.
• Ability to facilitate an additional payment to select pharmacies.
• Ability to offer competitive administrative fees and aggressive pricing / performance guarantees.
• Flexibility to work with Troy Health to make formulary and network adjustments when requested.
• Adherence to Troy Health’s contractual terms and requirements.
• Commitment to providing and ensuring high quality health care using innovative or value-based programs.
• Ability to provide Troy Health participants with efficient benefit administration and utilization review services that improve health outcomes and manage costs.
• Methods of providing effective / efficient customer service support and program information to providers and participants, including online and mobile capabilities.
• Ability to provide high quality specialty drug distribution that improves health outcomes while controlling costs and minimizing waste.
Update: After months of interviews and discussions with a handful of PBMs, we completed our RFP and selected PerformRx as our PBM. We are excited as PerformRx accommodated all of our requirements above and look forward to bringing transparency to pharmacies.
