PBM Request for Proposal

Describe your corporate ownership structure. Are you affiliated with or owned by a health insurer, pharmacy chain, or wholesaler?

Do you own or have financial interests in any mail order, specialty, or retail pharmacies? Disclose all affiliations.

Do you own and control your core claims adjudication platform, or do you license/outsource it? Identify the platform and any third-party dependencies.

Do you use a rebate aggregator or GPO for rebate management? If yes, identify the entity and ownership.

Are you willing to provide annual full disclosure of all revenue sources related to this client?

Has your organization been subject to any state or federal regulatory action, investigation, or enforcement in the past 5 years?

Are there any pending lawsuits, class actions, or regulatory proceedings involving your PBM operations?

Describe your incident response plan for data breaches involving PHI and your HIPAA BAA terms.

Confirm your organization will underwrite a one-time payment of $27,500 for Pharmacy Benefit Management (PBM) RFP. Note: Awarded PBM will be invoiced by Pharmacy Consultant for this fee at time of award notification. This fee is expected to be underwritten and not invoiced to the client through administrative fees.

Confirm your organization will underwrite payment of $2.25 PMPM to Pharmacy Consultant for ongoing contractual monitoring and clinical oversight. Note: This fee can be invoiced by Pharmacy Consultant to PBM or PBM can directly facilitate that payment to Pharmacy Consultant.

For the fees in Questions 1 and 2, please note where these fees are underwritten (allowance dollars, administrative fee, or underwritten within the overall pricing/rebates?)

PBM will not contact the client directly during the RFP process, unless as incumbent PBM for purposes of doing business as usual.

RFP response and any BAFO negotiations become part of the contract. Where discrepancies exist, the more favorable term to the client shall control.

Please confirm you have data exchange connectivity with UnitedHealthcare.

If not currently connected/integrated, please confirm you are willing to connect at no additional cost to client.

PBM will be able to successfully implement the plan with at least a 90-day implementation timeline.

Please confirm you are able to accommodate plan design changes at the state level based on legislation that may be enacted within a specific state where the client may have employees that reside.

Confirm all member calls and inquiries will be addressed by U.S.-based staff.

Describe your proposed account team's experience working with clients of similar size and scope.

For implementation, describe your transition-of-care approach for members on active specialty or complex therapies.

How frequently do you conduct client performance reviews? Describe your escalation process for issue resolution.

Confirm your brand drug definition includes single source and multi-source products only. Single source generic drugs will not be classified as brand drugs. All brand drugs with MediSpan codes of M, O, N will be classified as a brand drug.

Confirm your generic drug definition includes single source and multi-source products. All generic drugs with a MediSpan code of Y will be classified as a generic drug.

340B claim means any claim identified by the submission of "20" in any submission clarification code fields and/or a claim submitted with 340B indicator code of "38" as defined in Section 340B(a)(4) of the Public Health Service Act.

For your pass-through pricing model, confirm you operate on a true pass-through basis with zero spread between ingredient cost paid to pharmacy and charged to plan.

Do you agree upon request to provide, a sample of 100 adjudicated claims showing ingredient cost paid to pharmacy vs. ingredient cost billed to plan as verification of no spread.

Confirm members will pay the lower of U&C, MAC, copay, or discounted AWP ingredient cost for retail, mail order and specialty claims.

Does your dispensing fee differ for LTC, Home Infusion, Compound, VA, or ITU claims? If so, please indicate that amount.

Does your admin fee differ for LTC, Home Infusion, Compound, VA, or ITU claims? If so, please indicate that amount.

Please confirm if financial arrangements would be required to be modified as a result of government action, the resulting financial impact will be economically equivalent for client.

Please confirm each gurantee component is measured on a stand-alone basis and an overachievement on one guarantee component will not be netted against an underachievement in another guarantee. Gurantee components are: - Retail 1-83 days supply - Retail 84+ days supply - Mail Order - Specialty Brand - Specialty Generic - LDD

Rebates and discount guarantees stand alone and and may not be used to offset any other guarantee or to offset each other.

Any guarantee shortfalls will be paid out on a dollar for dollar basis, and any other program savings (i.e., cost containment) will not be used to offset the guarantees.

Confirm you are passing through the greater of 100% of rebates received or the minimum rebate guarantees.

Confirm client will receive all manufacturer revenue, including direct and indirect revenue received from manufacturers, GPOs, or others, as well as other fees such as administrative fees, inflation protection, marketing, educational or other.

Confirm biosimilars are included in the rebate guarantees?

If biosimilars are not included in the rebate guarantees, confirm the rebates received will still be passed through to client.

Confirm you will remit all rebates received to client on a quarterly basis within 90 days after the end of the submitted quarter.

Confirm your organization will provide NDC-11 rebate reporting at the time of rebate payments to client.

Please confirm you will provide a 60-day notification of any network change?

Please confirm you will provide a 60-day notification of any pricing change with an estimated financial impact of the pricing change?

PBM shall provide 60-day advance written notice of any formulary change. Plan reserves the right to approve, reject, or modify exclusions and tier placements.

Confirm you will provide financial gurantee reconciliation within 120 days after the end of the year.

Confirm you will provide rebate gurantee reconciliation within 150 days after the end of the year.

Confirm contract turnaround within 15 business days and response to redlines within 10 business days.

Confirm you agree to an annual market check.

As a result of the market check, if client/consultant determines current pricing is less favorable than the market, your organization agrees to enter into good faith negotiations to reach mutual agreement on pricing terms. If agreement is not reached, client has ability to terminate the agreement.

Client shall have the right to conduct an annual PBM audit, including pricing components, financial guarantees, rebate guarantees and manufacturer rebate agreements.

Client shall have the ability to audit aggregator/GPO's rebate contracts

Please include your contratual language relative to client's audit rights.

Please confirm you will provide line-item Rx claims data to client, consultant(s), and other third parties as needed in an agreed upon format, on at least a monthly basis at no additional charge, including a feed to both the USI and TeliosRx data warehouse.

Confirm client and their consultant(s) will have unlimited license access to online reporting system.

Describe your reporting portal, ad hoc capabilities, and real-time claims dashboards. Are these offered through a client portal?

Confirm client has the ability to choose a one-year agreement with annual renewal option or a three-year agreement.

Confirm the client will have the ability to terminate the contract at any time without cause, with a 90-day notice and will not be subject to any early termination penalties or fees.

All earned but unpaid rebates will belong to the client upon termination, regardless of reason. (i.e., in the event of termination, client shall receive all rebates earned as of the date of termination).

Confirm upon termination, you will provide all requested transition files, including open mail order files, open prior authorization, claims history and specialty pharmacy transition file at no charge to client.

Does your organization allow for use of third party or alternative funding programs, such as patient assistance (needs based), international sourcing, prior authorization carve-out, etc.?

Is your organization integrated/connected with Mark Cuban Cost Plus Drugs?

If offering an international sourcing program, identify all countries from which drugs are sourced. Are all sourcing pharmacies and wholesalers licensed and inspected by their respective national regulatory authority?

What liability and indemnification protections does your program provide to the plan sponsor in the event of a product safety issue, recall, or regulatory enforcement action related to internationally sourced drugs?

For traditional copay cards at large retailers (CVS, Walgreens, Walmart), how are you managing conversion?

What performance guarantees do you offer for your cost containment solutions?

Describe your white bagging / brown bagging capabilities and policies.

How do you manage specialty accumulator/maximizer programs?

Describe your specialty clinical management (therapy management, adherence, outcomes tracking) and key strategies in managing specialty medications.

Describe your oncology / high-cost infusion management program, site of care optimization and medical vs. pharmacy benefit coordination.

Describe your approach to managing cell and gene therapy drugs (e.g., Zolgensma, Hemgenix, Casgevy).

What stop-loss / reinsurance integration support do you provide for high-cost gene therapy claims?

Do you offer outcomes-based or installment payment arrangements for cell and gene therapies?

Describe your proposed formulary: tier structure, exclusion list, customization options, and P&T committee process.

Describe your prior authorization program — clinical criteria, turnaround times, appeals, and step therapy rationale.

Describe your approach to managing GLP-1 / obesity medications — clinical criteria, formulary positioning, and cost management.

Describe your process for evaluating whether a formulary placement decision is driven by clinical evidence vs. rebate economics. Provide an example.

Do you have any outcomes-based or value-based contracts with manufacturers? Describe and identify which drugs are covered.

Provide your book-of-business PA approval rate, average turnaround time (hours), and overturn rate on first-level appeal — broken out by: brand, specialty, and GLP-1 categories.

Describe your compliance with CAA Rx reporting requirements (Section 204).

Confirm you can provide required prescription drug data elements for gag clause attestation.

Are you compliant with state rebate pass-through requirements (where applicable)?

Are you willing to act in a fiduciary capacity on behalf of the client for pharmacy benefit management services?

Will you provide a formal annual fiduciary attestation letter confirming adherence to fiduciary duties and full financial disclosure?

Describe your retail pharmacy network, including total pharmacies, and any restrictions.

Describe your mail order pharmacy capabilities, including turnaround times and member digital experience.

Describe your specialty pharmacy model (open/exclusive/hybrid).

Describe your pharmacy disruption management and member communication approach during a PBM transition.

Confirm your standard contract contains no gag clause: nothing restricts the plan's access to its own de-identified claims data, provider-specific cost or quality-of-care information, or the plan's ability to share that data with its business associates (CAA Section 201).

Confirm you will provide the plan the contract terms and support needed to submit the annual Gag Clause Prohibition Compliance Attestation (GCPCA), and identify who attests: you on the plan's behalf, or the plan relying on your written confirmation.

Confirm you will disclose all direct and indirect compensation, including amounts to affiliates, subcontractors, GPOs, and rebate aggregators, as required under ERISA Section 408(b)(2)(B), before contract execution and upon any change.

Confirm you will complete the annual RxDC prescription drug data collection reporting (files D1-D8 and associated P files) on the plan's behalf at no additional fee, and identify any data elements the plan must supply.

Confirm the plan owns and may receive all of its claims data in a usable electronic format at no charge, within 30 days of request, during the term and after termination.

Confirm you will provide the data, UM criteria, and cooperation needed for the plan's MHPAEA NQTL comparative analysis wherever your utilization management applies to mental health or substance use disorder drugs.

Confirm you support the plan's Transparency in Coverage obligations, including the prescription drug machine-readable files, at no additional fee.

Confirm the plan's right to audit compliance with each item above with an auditor of its choosing, without a materiality threshold or vendor-mandated audit firm restrictions.

Confirm that, for plan years beginning on or after August 3, 2028 (January 1, 2029 for calendar-year plans), you will remit 100% of all manufacturer rebates, fees, alternative discounts, and other remuneration, including amounts received by any affiliated or contracted rebate aggregator or GPO, to the plan quarterly within 90 days of quarter-end, retaining only flat, fair-market-value bona fide service fees, as required by the Consolidated Appropriations Act, 2026.

Confirm you will provide the CAA 2026 standardized reports at least semiannually (quarterly upon request), including gross and net drug spend, all rebates and fees received, spread pricing amounts by pharmacy, formulary placement rationale for high-cost drugs, and PBM-affiliated pharmacy dispensing data.

Confirm the plan may audit your rebate and compliance records at least once per plan year under CAA 2026 using an independent auditor selected solely by the plan fiduciary and not funded directly or indirectly by you.

Confirm you will comply with the U.S. Department of Labor's PBM fee-disclosure regulation under ERISA 408(b)(2), including drug-level disclosure by channel, upon finalization and at no additional fee. (Proposed January 2026; pending as of this RFP.)

Confirm no provision of your proposed contract restricts or delays the plan's receipt, use, or disclosure of compensation, pricing, or claims data required under CAA 2026, and that you will indemnify the plan for penalties arising from your late or inaccurate reporting.

Confirm you will provide written certification of full rebate remittance each quarter sufficient for the plan to satisfy the CAA 2026 innocent-fiduciary conditions, and will notify the plan within 30 days of any failure to remit.

For any Medicare Part D or EGWP business, confirm your compensation complies with the CAA 2026 bona fide service fee (delinking) requirements effective plan year 2028, and that you will furnish the standardized annual Part D report, first due July 1, 2028.

Confirm you hold and will maintain all required state PBM licenses and registrations in every state where plan participants reside, including California SB 41 licensure and its fiduciary-duty standard where applicable, and will notify the plan within 30 days of any denial, suspension, or revocation.

Please confirm pricing does not change with a 1-year agreement.

Are these credits/clawbacks factored into your rebate estimate shown above?

Do you receive manufacturer administrative fees, data fees, or other compensation beyond rebates? Please describe.

Provide your implementation credits/allowances, the amount and basis (flat $, PEPM, PMPM), and the payment frequency (one-time or annual).

Provide any pharmacy management allowance, pharmacy consulting fund, or similar allowance, the amount and basis, and the payment frequency.

GLP-1 Management: describe your GLP-1 management program, eligibility criteria, expected engagement, program fees, and the net savings estimate for a plan of this size.