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Christopher Cannon, NASTAD U.S. Virgin Islands ADAP and Georgia ADAP
April 3, 2014
PBMs: From RFP To Implementation
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Evaluation
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Presentation Agenda
• Introduction: What is a PBM?
• U.S. Virgin Islands ADAP: Step-by-Step PBM Selection and Implementation
• Georgia ADAP: Lessons Learned
• Resources
• Question and Answers
• Evaluation
What is a PBM?
What is a PBM?
A PBM or pharmacy benefits manager is an organization or system that provides administrative and pharmacy claim adjudication services, pharmacy benefit coverage programs, and drug utilization functions. Some may also have arrangements with mail-order pharmacies.
PBMs do not adjudicate insurance claims; pay insurance premiums, deductibles, or co-payments; adjudicate medical claims; or pay medical co-payments.
What is a PBM?
79% of ADAPs have a contract with a PBM. Benefits of PBM Contract:
– created a statewide pharmacy network and claims adjudication system
– better facilitation of TrOOP with CMS – facilitation of client-level data reporting to HRSA – increased ability to collect rebates and back-bill – increased eligibility and re-certification screening
efficiency – reduced dispensing and distribution costs – increased medication inventory control – provided adherence counseling services and
monitoring of clients.
What is a PBM?
Challenges of PBM Contract:
– software training and integration with established data systems is difficult
– corporate culture versus public health priorities
– customer service needs versus response times.
Step-by-Step PBM Selection and Implementation
Pharmacy Benefit Manager (PBM):
From RFP to Implementation
Presented by: Virgin Islands Ryan White Part B/ADAP Program
Presenters:
Gary A. Smith, Project Director
Dianne Henry-Malone, ADAP/Data Coordinator
Why hire a PBM?
Assist with contract and compliance monitoring of ADAP
providers;
Develop, implement and maintain an online claims processing
database that will track and approve medication dispensing claims;
Create and submit monthly invoices on behalf of the ADAP
pharmacies with preapproved ADAP allowable claims;
Produce bi-weekly client-level data regarding number of clients that
picked-up their medications on time. This information will be
shared with case managers to contract clients to assist with
addressing any mitigating barriers;
Ensure accurate third-party billing occurs at each dispensing
transaction by rejecting medication dispensing claims submitted by
pharmacist for clients that have other insurance types;
Why Hire a PBM (continued)?
Assist the Program with preparing documentation to submit to
pharmaceutical companies to begin receiving rebates. The income
derived will support the administrative cost of the PBM, as well as
provide needed funds that will supplement reduced federal and
local funding;
Assist the program in making more accurate medication purchasing;
and
Assist with oversight of the ADAP formulary and mandated bi-
annual updates.
Request For Proposal (RFP) Process
Preparation of Scope of Services;
Comparison of V.I. Scope of Services with
other Ryan White program’s Scope of
Services;
Submission of Scope of Services to local
Property & Procurement Department
(P&P);
RFP submitted to local media as well as
online media.
RFP process (continued)
Review of proposals by P&P staff;
Ensure that all requirements of the RFP were
responded too as written and requested;
Interview & Evaluation process by P&P staff in
conjunction with Ryan White staff; and
Selection of PBM which best met our needs.
Implementation Process
PRE-IMPLEMENTATION MEETINGS
Discovery meeting held with PBM; and
Scheduled weekly implementation calls with PBM.
CONTRACT STATUS
Discuss contract strategy with PBM, i.e., who is point of contact, who will manage contract; and
Finalize and execute contract.
Implementation Process (continued)
ELIBILITY PROCESS
Discuss eligibility process, update frequency & type of file;
Determine method of transmission;
Determine ID number origin and additional requirements;
Perform first eligibility test file; and
Discuss test results with PBM.
Implementation Process (continued)
MEDICARE PART D DATA SHARING
Determined that PBM will assist with CMS file submission / data sharing;
PBM initiated contact with CMS to begin data exchange implementation;
PBM will send first test file to CMS; and
PBM will send first production file to CMS.
Implementation Process (continued)
FINANCE
Determine billing / finance point of
contact;
Determine billing frequency; and
PBM provided a sample of invoicing
reports and billing information.
Implementation Process (continued)
ID CARD PRODUCTION
Discussed ID card layout with PBM;
Determined mode of distribution and
timeline for delivery of cards;
Received ID card and welcome letter
draft from PBM; and
Provide approval of ID card and welcome
letter.
Implementation Process (continued)
SYSTEM ACCESS
Provided staff names for access to PBM system; and
Implementation of set-up and training by PBM.
MEMBER SERVICE
Set-up services support needs, i.e., business hours, after-hours, weekends, holidays; and
Implemented dedicated PBM toll free number for pharmacy services.
Implementation Process (continued)
PHARMACY NETWORK
PBM executed contracts and set-up with pharmacies.
REPORTING
Provided PBM with reporting needs and frequency of plan performance reviews.
Implementation Process (continued)
REBATE ADMINISTRATION
Discussed rebate needs and the need for
recoupment services.
Challenges of PBM process
Bureaucracy of the V.I. local government
processes; and
Resistance of pharmacies to the new
process.
Outcomes of PBM process
Initial savings of 25% on dispensing fees;
Accuracy of dispensing fees billing is now
electronic vs. manual verification;
Eligibility verification is performed
electronically;
The electronic monthly reports are now
assisting with inventory reconciliation; and
Various reporting requirements are now
available electronically.
Lesson Learned
Presentation to:
Presented by:
Date:
PBM Webinar
Pharmacy Benefit Manager
Experience--
The overall goal of putting out an RFP for new a PBM
was to expand services for ADAP clients and provide a
more modernized and efficient system.
Assess the needs and services required for your program
(e.g. online adjudication, pharmacy network, COB,
electronic reporting, formulary maintenance, eligibility,
electronic applications, etc.)
Pharmacy Benefit Manager
Services--
Programmatically, the GA ADAP was seeking to implement a more modernized and efficient system for an electronic eligibility assessment process; electronic ADAP application and recertification process; Clients’ Medicaid status confirmation; Coordination of benefits assessment for Medicare, Medicare Part D and other insurance companies; and a tracking and reporting system for coordination of benefits services. The ADAP was also seeking a faster and more efficient process for paying health insurance premiums.
Request for Proposal (RFP)
Process--
Identified deliverables as to what the PBM will do is identified.
Submission of a Contract Action Request is completed. This form is the initial form that is needed to start the process.
Procurement meets with the Business Owner , ADAP Manager and Pharmacy Director to discuss the next steps and develop a timeline with the RFP process (project plan). A committee is formed to review and score the proposals once the posting closes (can be persons in the department who have knowledge).
Request for Proposal (RFP)
Process-- The RFP for the Pharmacy Benefit Manager (PBM) is posted to
the Department of Administrative Services (DOAS) for a minimum of 10 days and a maximum of 30 days.
Vendors interested in the bid submits their proposals by the date set. Proposals sent after the closing of the bid will NOT be accepted under any circumstances.
Any questions that the vendors have are to be directed to the Procurement specialist only!
All vendors must meet the requirements through a series of questions. The category for the questions are (a) mandatory, (b) mandatory scored, and (c) additionally scored.
The committee meets to score all vendors deemed eligible.
Request for Proposal (RFP)
Process-- If the vendor does not meet the criteria for the
mandatory requirements, they are automatically disqualified from the bid.
Once all qualified vendors have been scored one is selected to fulfill the requirement of the PBM.
Public Notice of the contract identifying the successful bidder is posted.
The selected vendor finalizes the contract agreement by a agreeing to all terms.
The funding period each is April 1 to March 31. The contract also has four (4) renewals AFTER the initial contract.
Pharmacy Benefit Manager
Transition--
• The transition included 3-4 months of data testing
and transference for both the pharmacy component
and enrollment/eligibility component in preparation
for full implementation effective April 1, 2013.
• In addition to data testing, there were numerous
technical conference calls held in preparation for
implementation.
• An enrollment site within the local metro area was
selected as a pilot site for the initial implementation.
Pharmacy Benefit Manager
Challenges--
Providing a seamless electronic eligibility and
enrollment process during the initial
implementation stages.
Pharmacy Benefit Manager
Lessons Learned--
Confirm with winning bidder their understanding of contract language
Assess the specific needs and services required for your program (e.g.. Pharmacy services, Program services)
Design technical evaluation, mandatories and scope of work to allow you to differentiate/score each vendor
Request “real-time” access to the PBM in order to monitor services at anytime
Be specific in the Scope of Work regarding methodology, timelines, implementation and execution.
Work closely with legal team to assure strong language and tangible consequences for non-compliance with deliverables
Double check/perform QM audits on reports, data deliverables of the PBM services to assure compliance
Resources
Resources
National Alliance of State & Territorial AIDS Directors (NASTAD), www.NASTAD.org – Christopher Cannon, ccannon@NASTAD.org
– Fact Sheet: PBM and IBMs – Webinar: Insurance and PBM utilization – Fact Sheet: ADAP Contracts with PBM – PBM Proposal Template – PBM Request for Proposal Example – PBM Contact List – PBM Contract Bank and Things to Consider Release of web based PBM toolkit in late April/early May.
Question & Answers
Thank You. Evaluation will follow the conclusion of the
webinar
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