Please note newly adjusted time frame:
Bid Posted Date January 14, 2019Vendor Comments & Questions Due Date/Time January 18, 2019Answers Posted Date/Time January 24, 2019
Second Comments & Questions Due Date January 31, 2019Answers Posted Date/Time February 8, 2019Bid/Proposal Due Date/Time February 22, 2019Tentative Award Announcement Date March 22, 2019Anticipated Contract Start Date May 1, 2019
1. As part of the managed care contract, does the Coalition cover all medically necessary services or just services related to behavioral health?
Under the Tailored Plan, the managed care contracts will cover all physical health and behavioral health services related to the membership.
2. How many recipients does the Coalition provide pharmacy benefits to?
The Department of Health and Human Services estimates that approximately 120,000 persons statewide will be eligible to enroll in Tailored Plans. Tailored Plan contracts will be awarded by region. The percentage of the state that the Coalition members will collectively serve as Tailored Plan participants is not yet known, but will likely exceed 50% of statewide Tailored Plan enrollment. We do not currently provide pharmacy benefits but based on the Tailored Plan information, we estimate the following:
Alliance – 29,310Trillium – 26,944Vaya – 29,202Total – 85,456
3. What is meant by uniform PDL in question number 9? To what extent does the uniform PDL control all drugs? For example, does the PDL only dictate the top 90 therapeutic classes?
Uniform PDL refers simply to the Preferred Drug List dictated by the State Contract. The State has not yet defined the extent. We currently believe that for a drug to be covered by the contract, it will have to be included on the list. This is subject to change as part of our work with the consultant and further discussions with the State.
From the standard plan RFPc. Drug Formulary and Preferred Drug List i. The PHP shall not be allowed to maintain a closed formulary as defined in N.C. Gen. Stat. § 58-3-221(c)(1).
ii. In accordance with Section 5.(6)b. of Session Law 2015-245, as amended by Session Law 2016-121, the PHP shall use the same drug formulary established by the Department.
iii. The drug formulary shall, at minimum, include: a) All drugs included the North Carolina Medicaid and NC Health Choice Preferred Drug List (PDL) as posted on the Department’s website. The PHP shall refer to the Pharmacy Services page on the Department’s website, for a current listing of covered drugs on the North Carolina Medicaid and NC Health Choice PDL.
b) All other covered drugs in drug classes not listed on the Department’s PDL; and
c) Outpatient drugs that are not excluded through state or federal policy, as defined in 42 C.F.R. § 438.3(s)(1).
Coverage Requirements– State must cover every FDA approved drug, subject to limited exceptions (e.g., weight loss, fertility, hair loss, vitamins)– State must cover all drugs immediately after FDA approval (though rarely followed)– State may subject drugs to prior authorization, but cannot deny access for medically-accepted indications– Must respond to request for prior authorization within 24 hours and provide at least a 72-hour supply in case of emergency
Specifically in NC: MCOs have little flexibility– MCOs must follow the existing FFS clinical coverage policies and prior authorization criteria– No prior authorization is allowed for antihemophiliac factor drugs– Beginning in year 2, MCO may submit alternative pharmacy clinical coverage and prior authorization
4. What restrictions exist, if any, in North Carolina for the pharmaceutical treatment of behavioral health?
No restrictions are currently known.
See answer # 3 above. You can also refer to the current Preferred Drug List to see the current preferred and non-preferred behavioral health medications. It is located at https://files.nc.gov/ncdma/documents/files/PDL_2018-2019_DEC-27-2018.pdf
5. Regarding question 20, is the question concerning financial outcomes, or non-financial outcomes (such as account service, network availability, claims processing timing guarantees, etc.)?
We are looking for best practices as related to the specific performance and outcome monitoring that should be included in the PBM contract. We are interested in both financial and non-financial outcomes. We encourage the applicant to take this question in whatever direction it desires. Intent of question was to elicit input on access, quality, and financial performance outcomes.
6. Regarding question 24, is the intent to have one contract between the PBM and the Coalition, or is the intent to have individual, potentially customized contracts between the Coalition members and the PBM?
Each Coalition member will hold a separate contract with the PBM, which may be customized.
7. Regarding question 25, can additional evaluation of the proposal occur outside of the three day on-site proposal evaluation?
Yes. Applicant can recommend a different review process and provide costs for that process.
8. How many distinct pharmacy plan designs do the Coalition members have that will be participating in this PBM?
We are anticipating a single pharmacy plan to meet the contract requirements of the State but the requirements could change.
9. Can you please provide membership projections for each of the coalition members, Alliance Health, Trillium Health Resources and Vaya Health on an annual basis for the first three years of operations? See response for #2
10. For assisting in the development of the pharmacy benefit plan for the special populations will this be one plan for all three coalition members, or will it be specific to each plan?
11. Will the coalition select one pharmacy benefit manager (PBM) partner for all three members, or will members be permitted to select a PBM different from the one chosen by the coalition?
The Coalition members are permitted to select their own individual PBM.
12. Will the PBM functionality be carved out from medical for all three members of the coalition?
The PBM functionality will be included in the services provided by the Tailored Plans.
13. For the PBM request for proposal (RFP), in addition to the common requirements will each of the coalition members have their own unique set of bidder requests and requirements?
No. The Coalition will be bidding for the PBM with one RFP.
14. Does the coalition plan on conducting the scoring of the PBM sections with assistance from the consultant or will the consultant lead this effort?
No final decision has been made on this point at this time.
15. For the coalition’s role on conducting the PBM scoring, how will the responsibilities be divided among the three members?
A Committee made up of Coalition members will be conducting the scoring.
16. Will the coalition hold the contract with the PBM, or will each coalition member hold its own contract with the selected PBM?
Even if each coalition member ultimately will hold its own contract, will there be (at least some) PBM contract negotiations on behalf of all three members of the coalition. In other words, is it contemplated that there might be a combination of a joint negotiation with certain sections that will be specific to each member of the coalition? Each Coalition member will hold a separate contract with the PBM, which may be customized, however, there may be joint negotiations with certain sections; that has yet to be decided.
17. Has the coalition determined the number of PBM bidders that will be included in the RFP?
18. Will the coalition want to conduct site visits for PBMs that are selected as finalists?
We welcome input from the consultant as to the value of this as well as the value of the finalist PBMs providing presentations to the Coalition.
19. Are there any unique requirements, functionalities or services that the coalition is looking for in a PBM partner?
The RFP conveys the Coalition’s unique needs and desires regarding creating optimal pharmacy benefits management for individuals with significant behavioral health needs.
20. Will the pharmacy consultant be asked or required to interact with NC Medicaid or the North Carolina Department of Insurance (NCDOI)?
Each MCO will be responding to the State RFP. All questions should be routed through the Coalition Member. We do not see need for interaction with NC State agencies at this time.
21. For the PBM consulting services RFP, are bidders allowed to team with other organizations when responding (e.g., legal expertise to facilitate the drafting of the PBM contract(s))?
Yes. A multi-organization bid is acceptable, with a primary bidder and one or more subcontractors.
22. What services is the Coalition looking to outsource to the PBM versus insourcing to the Coalition, if any?
Specifically, claims, utilization management, and possibly other functions. No final decisions have been made at this time. We are seeking the consultant’s input regarding optimal “buy vs. build” (or direct performance) approaches to fulfilling each needed pharmacy benefits management function.
23. Will each coalition member have its own contract with the selected PBM, requiring three (3) separate contracts to be negotiated/managed?
Each Coalition member will hold a separate contract with the PBM. The contracts will be as similar as possible.
24. Does the Coalition want bidders to provide pricing for the Suggested Ongoing Support mentioned in Item 27?
Pricing is welcome but not required for the suggested ongoing support tasks.