Solicitation: 200373
The primary role of a contractor is to review (PA) and (ST) that are submitted by plan sponsors to CMS. Plan sponsors submit PA and ST group descriptions on their formulary file with corresponding tab delimited PA and ST files. Each PA group description contains the following criteria elements: PA Indication Indicator, Off-Label Uses, Exclusion Criteria, Required Medical Information, Age Restrictions, Prescriber Restrictions, Coverage Duration, and Other Criteria.
ST group descriptions contain only one criteria field that describes the ST protocol. Also, the criteria must be aligned with the step placement of drugs on the formulary file. Criteria elements contained in each field of a PA or ST group description must be reviewed for approval.
The PA and ST criteria review is conducted annually for the upcoming contract year and monthly for the current contract year. For the annual review, there are around 110,000 PA group descriptions and 5,500 ST group descriptions. For the monthly review, there are approximately 3,000 PA group descriptions and 500 ST group descriptions.
Skills required of the contractor shall include:
- Knowledge and understanding of the Medicare Prescription Drug, Improvement and
- Modernization Act (MMA) of 2003 and the Medicare Prescription Drug Benefit Manual.
- Knowledge and experience with pharmacy benefit management practices involving PA and ST criteria.
- Ability to accurately and consistently review sponsor submitted PA and ST criteria based on appropriate clinical parameters and deliver to CMS within specified contractual timeframes.
- Ability to analyze large data sets, including text and formulary files, using appropriate software packages such as Access and SAS.
The major tasks for Medicare Part D Formulary Utilization Management Review include:
Review and evaluate the appropriateness of ST and PA criteria to ensure that utilization edits are not overly restrictive and are consistent with approved drug labeling, Part D compendia, and widely accepted treatment guidelines.
Compile large tab delimited text files into an Access database for delivery to CMS with criteria identifiers for each unique text…
