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.

No agreement between the PBM and the plan sponsor, and no agreement between the PBM and its subcontractors or downstream entities, contains any provision that directly or indirectly restricts the plan from accessing de-identified claims data, provider-specific cost or pricing information, or from sharing that information with the plan's business associates and advisors.

The PBM will provide written confirmation of gag clause compliance each year, in time to support the plan's Gag Clause Prohibition Compliance Attestation due December 31, and will identify any contract provision that could require disclosure in the attestation.

The PBM provides the plan sponsor and its designated consultants electronic access to complete de-identified claims data, including plan paid amounts, pharmacy reimbursement amounts, and rebate detail, to the full extent permitted by law.

The PBM prepares and submits the pharmacy data files (D3 through D8) for the plan's annual RxDC filing by the June 1 deadline each year, at no additional charge.

The PBM will provide plan-level data, not aggregated-only data, to the plan sponsor upon request, and will supply any data elements the plan or its other vendors need to complete the D1 and D2 files.

The PBM confirms each year's RxDC submission in writing and coordinates with the plan's other reporting entities, such as the medical TPA or issuer, to prevent gaps or duplication.

The PBM acknowledges that it is a covered service provider under ERISA Section 408(b)(2) and will disclose in writing, before the contract is entered into, renewed, or extended, all direct and indirect compensation that it, its affiliates, and its subcontractors expect to receive in connection with the plan.

Compensation disclosures itemize revenue by source and type, including manufacturer-derived revenue, retail network spread, affiliate pharmacy margin, rebate aggregator or group purchasing organization retention, data sales, and interest or float earned on plan funds.

The PBM will provide updated disclosure promptly following any change in its compensation arrangements and will respond to plan sponsor requests for compensation information within the timeframes required by ERISA Section 408(b)(2).

The PBM contractually passes through to the plan 100 percent of rebates, fees, alternative discounts, and all other remuneration received from manufacturers or third parties that is attributable to the plan's utilization.

Rebates and other remuneration are remitted at least quarterly and no later than 90 days after the end of each quarter, with reconciliation and payment of any prior-period underpayments.

The only amounts the PBM or its affiliates retain are bona fide service fees that are transparent, fixed, stated in the contract, and consistent with fair market value.

Remuneration received by rebate aggregators, group purchasing organizations, and other affiliated or offshore entities in the PBM's ownership chain is disclosed, included in the 100 percent pass-through, and supported by records available for plan audit.

The PBM will deliver the full transparency report required under ERISA Section 726 at least semiannually, and quarterly upon plan request, in plain language and machine-readable format, at no additional charge.

Reports include drug-level detail: amounts charged to the plan, amounts reimbursed to dispensing pharmacies, any difference retained (spread), participant cost sharing, and rebates and discounts received, for each drug.

Reports include therapeutic class summaries: gross and net spend, PBM claims-related revenue, average costs for 30-day and 90-day fills, participant counts, and formulary tier placement.

For each high-cost drug (annual gross spend above $10,000, or the top 50 drugs by spend), reports include the rationale for formulary placement and any year-over-year formulary changes.

Reports include affiliated pharmacy detail: benefit design features that encourage use of PBM-affiliated pharmacies, the percentage of claims dispensed through affiliates, and drug acquisition cost for claims dispensed through affiliates.

The PBM will provide participant-facing summary documents, respond to participant requests for claim-specific detail, and support the plan's required annual notice to participants about the availability of this information.

No contract between the PBM and any third party limits, or will limit, the PBM's ability to provide the required reporting to the plan, and the PBM will not enter into such a contract.

The plan sponsor may audit the PBM's rebate and remuneration records, including aggregator and group purchasing organization records, using an independent auditor of the plan's choosing, without unreasonable restrictions on scope, frequency, or auditor selection.

The plan sponsor may audit claims at the claim level to verify pricing, guarantee performance, and pass-through performance, with full claim data provided at no charge in a usable electronic format.

Upon reasonable request, the PBM will make available the source data supporting its ERISA Section 726 transparency reports so the plan can validate report accuracy.

The PBM will incorporate the CAA 2026 pass-through, reporting, and audit requirements into contracts signed or renewed now, without waiting for the statutory effective date of plan years beginning on or after August 3, 2028 (January 1, 2029 for calendar-year plans).

The PBM acknowledges the CAA 2026 enforcement provisions, including civil penalties of up to $10,000 per day for reporting failures and up to $100,000 for knowingly providing false information, and accepts contractual responsibility for penalties caused by its own failure to perform.

The PBM will notify the plan sponsor promptly in writing of any failure to remit required amounts or deliver required reports, so the plan fiduciary can satisfy its oversight obligations, including the innocent fiduciary conditions under CAA 2026.

The PBM confirms that no term of its standard agreement conflicts with the requirements in this questionnaire, or has identified every conflicting term in the Explanation column.

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 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.)

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.