Nevada State Pharmacy Benefit Manager

Contractor shall provide comprehensive Pharmacy Benefit Manager (PBM) services to support the full Nevada Medicaid pharmacy benefit across all populations, including Fee-for-Service (FFS) and Managed Care Organizations (MCOs). Contractor shall perform all functions necessary to administer the statewide pharmacy benefit, including claims adjudication; formulary and preferred drug list development and maintenance; pharmacy network management; drug rebate negotiation, invoicing, and administration; and clinical and utilization management activities that promote cost-effective prescribing and improved clinical outcomes.

The Contractor shall provide comprehensive pharmacy benefit management (PBM) coverage for all Nevada Medicaid and Nevada Check Up members via a phased implementation:

• Contract Year 1: Coverage shall apply strictly to Fee-for-Service (FFS) members.
• Contract Year 2 and Thereafter: Coverage shall expand to include all members enrolled in managed care, with the Contractor operating as the State Pharmacy Benefit Manager across both FFS and MCO delivery for all Nevada Medicaid and Nevada Check Up members.

The Contractor shall be available during normal, Pacific Time, business hours, Monday through Friday, 8:00 AM to 5:00 PM (PT) with the pharmacy helpdesk being available 24 hours per day, 7 days per week, 365 days per year.

The Contractor shall have at least five (5) years of experience providing pharmacy management services for a state Medicaid program (Fee-For-Service (FFS) or Managed Care Organization (MCO)).

The Contractor shall participate in and commit to facilitating a successful CMS Certification process for the entire contract period, including extensions, if any.

The Contractor shall be a current National Council for Prescription Drug Program (NCPDP) member and maintain membership throughout the life of the contract.

The Contractor shall deliver a comprehensive suite of services to establish and oversee all elements of the NVHA, Nevada Medicaid single PDL, encompassing both pharmaceutical and non-pharmaceutical products.

The Contractor shall conduct eight DUR intervention mailings each year, including quarterly interventions for specific providers and two focused on NVHA-identified drug classes.

The Contractor shall accept prior authorization requests via phone, fax, or electronic methods, including ePA transactions, every day, including weekends and holidays. The Contractor shall provide responses (approval, denial, or request for more information) within 24 hours.

The Contractor shall maintain a Nevada Medicaid pharmacy website, providing public access to standard pharmacy website information, including but not limited to items such as PDLs, Provider Manuals, Billing Manuals, Prior Authorization forms and criteria, contact information, pharmacy network listings, and other necessary information.

The Contractor shall provide full-time key personnel dedicated to the contract and submit their names, positions, and contact information to the NVHA within sixty (60) days of contract award.

The Contractor's proposal shall address the Contractor's ability and willingness to amend agreements to accommodate alternate payment arrangements as deemed necessary by the NVHA.

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