The vendor is required to provide that, is seeking to procure a new, modern, and sophisticated pharmacy benefit administration solution (PBA), along with a robust rebate management service and system, and user-friendly analytics and reporting system to replace the legacy system and processes.
- Objectives for implementation and maintenance:
• Flexible system that allows for configuration in response to policy, market, and regulatory changes
• 24/7 call center ensuring immediate resolution for providers and billing and technical issues
• Efficient printing, mailing, accounting, and auditing services that are integrated with the solution
• Configurable and compliant pricing system allowing adaptability to meet all applicable requirements under federal and state law
• Provide a full set of tools and configurable parameters with a full set of tools to allow state to appropriately identify, track, and implement utilization management aligned with evidence-based medicine
• Provide a system that integrates with other systems (as shown in the concept of operations, figure 1) to enable efficient prescriber registration with the ability to incorporate pharmacy specific characteristics
• Rebate management system to ensure maximum value to the commonwealth in line with CMS requirements
• Innovative rebate management system that supports novel value-based contracting and other state sponsored rebate contracts
• Provide a dynamic claims adjudication system enforcing accurate real-time decision making
• Solution that adheres to state and CMS requirements for reporting and auditing needs
• Solution with administrative and reporting capabilities for authorized end users
• Solution with comprehensive bi-directional analytics environment providing multiple tools for trained users with varying abilities
• Solution that encompasses a longitudinal view to support whole member health
• Solution that ensures efficient information transfer through multi-channel communication with key state stakeholders
• Interactive public-facing drug list that reflects coverage policies and clinical management
• Solution that adopts EOHHS’ specific naming conventions on configurable system parameters/lists, where the key to the parameter can be set by the end users at multiple levels
• Solution with secure, efficient, accurate, and timely exchange and utilization of information across individuals, systems, and interfaces
• solution that maintains program integrity by monitoring for fraud, waste, and abuse
• Solution that maintains and conforms to all commonwealth and federal rules, regulations, and best practices
• Solution that ensures high-quality stakeholder experience while interacting with MASSRX
• Intuitive system that ensures business processes run efficiently and seamlessly
- the drug utilization review (dur) program, a division of university of state (UMASS) clinical pharmacy services, further supports agency in the administration of the program by performing certain clinical drug functions, including but not limited to:
• Prior authorization (pa) evaluations, transfers, and appeals
• Drug utilization review (dur) certifications
• Provider notifications
• Pharmacy lock-in program administration
• Policy exception and retrospective dur functions
• Clinical call center for prescribers and pharmacists
- The office of clinical affairs (oca’s) clinical team to manage the clinical side of the program’s services to develop, implement, and manage the following:
• The list of covered drugs, also referred to as the state drug list (MHDL) and the unified pharmacy product list (UPPL)
• Plan administration (benefit coverage maintenance)
• Prior authorization (pa) guidelines
• Clinical decision support
• Drug pipeline review and forecasting budgetary impact to the program, and
• Staff and support the state dur board with the oca clinical team
- Pharmacy claims system administration
• Benefit limitation and qualification rules
• Pricing rules
• Copay rules
• Third party liability (TPL) and related cost avoidance
• Master drug database administration
- Pharmacy claims adjudication
• Point of sales rules
• Editing and auditing
• Prospective dur
• Pricing
• Cost avoidance
- Prior authorization (pa)
• Automated pa processing
• Dur certification capabilities
• Policy overrides
- Drug rebate
• Administration for all pharmacy claims and encounters
• Federal drug rebates
• State supplemental and value-based rebates
• Resource support for federal drug rebate program and state supplemental drug rebate program
- Program’s web portal
• Public-facing website
• Pharmacy direct data entry (DDE) interface for claim submissions
• Secure repository for MCE encounter data submission and manufacturer invoice retrieval
- Program’s data warehouse
• Data repository of all pharmacy claims, encounters, member data, rebate data, etc.
• Data repository of member data, including patient profiles
• Data repository of provider data
• Data repository of related reference data (e.g., drug)
- Resource support
• Development activities for all applications
• Pharmacy provider relations and call center (help desk)
• Mail services
- Contract Period/Term: 5 years
- Mandatory/Non-Mandatory Pre-bid/Pre-Proposal Date: January 21, 2025
- Questions/Inquires Deadline: February 03, 2025