RFP #CCHR2026-2 Pharmacy Benefit Management Services

Cattaraugus County
Pharmacy Benefit Management Services
RFP # CCHR2026-2
Proposed Effective Date: January 1st, 2027
Presented by:
Arthur J. Gallagher & Co.
90A John Muir Dr
Amherst, NY 14228
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Table of Contents
Table of Contents ................................................................................................................. - 2 -
Confidentiality ...................................................................................................................... - 3 -
Introduction .......................................................................................................................... - 4 -
Objective ............................................................................................................................... - 6 -
Instructions .......................................................................................................................... - 7 -
PBM Corporate Information & References ......................................................................... - 8 -
Minimum Contractual Requirements .................................................................................. - 9 -
Written Response Questions ............................................................................................ - 15 -
Fulfillment ........................................................................................................................... - 18 -
Shipping ............................................................................................................................. - 19 -
Clinical Services ................................................................................................................ - 20 -
Formulary ........................................................................................................................ - 20 -
Prior Authorizations ....................................................................................................... - 21 -
Step Therapy ................................................................................................................... - 21 -
Quantity Level Limitations ............................................................................................. - 21 -
Utilization Management.................................................................................................. - 22 -
Incretin Mimetics ............................................................................................................ - 22 -
Specialty Medications .................................................................................................... - 23 -
Opioid Management/Fraud, Waste, Abuse ................................................................... - 24 -
Adherence ....................................................................................................................... - 24 -
Compounding ................................................................................................................. - 24 -
Pharmacogenomics ....................................................................................................... - 24 -
International & Alternative Drug Sourcing.................................................................... - 25 -
Other................................................................................................................................ - 25 -
Fees ................................................................................................................................. - 25 -
Member Service ................................................................................................................. - 26 -
Reporting and Website Capabilities ................................................................................. - 27 -
Data Requirements ............................................................................................................ - 29 -
Formulary and Pharmacy Comparison ............................................................................. - 30 -
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Confidentiality
This Request for Proposal (RFP #CCHR2026-2) and all information contained herein, any
attachments or exhibits hereto, and all communications in whatever media form, in support of this
document are proprietary to Cattaraugus County ("the Client"). Your firm acknowledges the
proprietary nature of the aforementioned described information and that your use of such
information for purposes other than a vendor/vendee relationship, or the disclosure of such
proprietary information to third parties other than for the purpose of advancing the intent of the
services contemplated by this document will cause irreparable injury to Cattaraugus County.
Vendor's breach of this covenant pertaining to the proprietary information will entitle Cattaraugus
County to automatic injunctive relief in addition to any and all other remedies available at law.
Acknowledgment
_____________________________
Name
______________________________
Company
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Introduction
Cattaraugus County will be involved in the selection of a Pharmacy Benefit Manager (PBM)
offering a comprehensive pharmacy benefit management solution for their approximately 967
employees and 2,489 members (including employees). The self-funded prescription plan
currently includes active employees, Pre-65 Retirees and COBRA members. Gallagher ("the
Consultant") is requesting on their behalf self-funded proposal for the administration of
pharmacy benefit management to Cattaraugus County ("the Client"). The response to this RFP
will determine the PBM best suited to assist the Client.
The client is looking for a two-year contract with a proposed effective date of January 1st, 2027.
Also, Cattaraugus County will be looking for a contract that provides for a market check to
review the competitiveness of their contract with the selected PBM after the first 12 months of
the contract. This Request for Proposal (RFP) will be asking for information about clinical
management, data management, as well as financial offerings. The overall purpose of this RFP
is to evaluate the capabilities of selected PBM's to meet the specific needs of the Client.
The bidding PBM will need to take into account the required integration with other benefit
providers including but not limited to Medical, Disease Management and Data Aggregation
vendors. The chosen administrator will be expected to bear the cost of preparation and
installation of appropriate administrative systems, contract preparation, billing, network
enhancements, related administrative manuals, enrollment forms, and communication with
employees and providers.
Nothing contained in this RFP creates, nor shall be construed to create, any contractual
relationship between the Client and any vendor. The Client makes no commitment in or by
virtue of this RFP to purchase any services or items from any vendor. Nor does receipt of your
proposal place the Client under obligation to enter into an agreement to purchase services from
your organization.
Your proposal shall become the sole and exclusive property of the Client. The Client reserves
the right to modify, reject, or use without limitation any or all of the ideas from the proposals.
The Client will not disclose the pricing contained in any proposal to any party other than its
attorneys, representatives, or consultants except as may be necessary to complete a blind
analysis of responses provided to this RFP. Vendors from whom proposals are solicited may not
discuss this RFP with anyone outside their own organization other than authorized the Client
personnel and, or their designee(s).
If your organization is selected to provide the outlined services, you may not advertise or publish
the fact that the Client has selected your company as their partner without written permission
from the Client. You are not allowed to use the Client name or any trademark of the Client in
any advertising or publication or other communication, other than in your proposal, without the
prior written consent of the Client.
Expenses incurred in preparing and presenting a proposal to the Client is the sole responsibility
of the vendor and may not be charged to the Client in anyway. This RFP is an invitation to share
information about your business model, clinical programs, and general insight into the
pharmaceutical marketplace which will help the Client determine which PBM(s) is best suited to
help them manage their plan. All aspects of the Client business to which you may have access
as a result of this RFP are considered strictly confidential.
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The Client is specifically interested in how the PBM performs in the following areas:
a) Discount guarantees with per-unit price stability
b) Administrative fee structure
c) Maximizing generic utilization
d) Percentage of earned rebates to the Client with minimum floor guaranteed
rebates, without overutilization of brand drugs
e) Performance Guarantees
f) Stable and decreasing PMPM (per member per month) spending trend
g) Stable formulary, focused on lowest net cost drugs
h) Drug monitoring and utilization review programs
i) Innovative programs, such as therapeutic mac, disease management,
therapeutic interchange programs, limited network strategies, retail pharmacy
partnerships, etc.
j) Periodic reviews - financial, clinical, market, strategic
k) Effective customer, client, and consultant communications and messaging.
l) Mail cost savings opportunities with incentives programs
m) Organizational stability and experience
n) Customer service representative and account manager capabilities.
o) Ability to work with the selected third-party claims administrators, data
aggregators, consultant and other entities that may be involved with the
administration of the health plan to provide up to daily electronic exchanges of
eligibility, and claims information
p) Online member information resources, including mobile applications
q) Biosimilar net cost strategy including guarantees, utilization management and
formulary placement
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Objective
The Client is looking for a long-term partner who will provide both the Client and the Consultant
with the resources needed in order to assist in managing the Client's pharmacy benefit. Any
responses provided in response to this RFP must be included in the client contract or the
selected PBM may be disqualified.
PROPOSED TIMELINE
Distribution of RFP Date
RFP Release April 20th, 2026
Questions to Gallagher via email
May 1st, 2026
Proposals Due to Gallagher - electronic submission
May 22nd, 2026
(preferred via email)
Proposal Analysis Completed & Presented to Client
June 2026
Finalists Presentations (if applicable) ASAP after Presented to
Client
Notification of Final Decision ASAP after Finalist
Presentations
Implementation (if applicable)
September 1st, 2026
New Contract with the Client
January 1st, 2027
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Instructions
1. Answer every question as designated in that section. If any assumptions are made in
providing an answer, those assumptions must be explicitly noted.
2. Provide all guarantees without commissions.
3. This RFP must be completed and submitted in its entirety according to the timeline above.
Missing responses will be grounds for disqualification from consideration. There is to be no
altering of the lay-out of this document in any way. Answers are to be provided in the
available space or in an attached appendix. No questions are to be deleted or altered in any
way.
4. The response must include one (1) electronic copy emailed to Jonathan Barnhard at
Jonathan_Barnhard@ajg.com and Nicole Hoffstetter at Nicole_Hoffstetter@ajg.com.
5. Failure to respond with the information requested or to provide written notice regarding why
you are unable to respond will indicate a lack of interest and the PBM may be removed from
the Client's list of potential vendors.
6. Organization of the Response
Section I - Letter of Introduction
Section II - This Document and the attached Questionnaire
Section III - Completed Financial Terms and Exhibits
Section IV - Contract Terms including a copy of the Proposed Contract
Section V - Excel Formulary
Section VI - Pharmacy Disruption
Section VII - Sample Utilization and Cost Reports
a. Access to online tools for clients, members, designees (the Client)
Any Additional Exhibits
7. All questions should be sent to Jonathan Barnhard at Jonathan_Barnhard@ajg.com and
Nicole Hoffstetter at Nicole_Hoffstetter@ajg.com with a carbon copy to Cindy Hammer at
Cindy_Hammer@ajg.com and Danielle Grew at Danielle_Grew@ajg.com.
8. Bidding PBM's must not reach out to the Client directly or indirectly during the RFP process.
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PBM Corporate Information & References
Name:
Date Founded:
Contact Person:
Title:
Address:
City/State:
Phone Number:
E-mail Address:
Fax Number:
Current Client References
Similar Size and Complexity
Client Name Contact Person Phone Number Total Members Contract Start
/ Address Date
1
2
3
4
5
Recently Termed Client References
Similar Size and Complexity
Client Name Contact Person Phone Number Total Members Contract Start
/ Address Date
1
2
3
4
5
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Minimum Contractual Requirements
For this section, CONFIRM your agreement with each of the below statements. If you cannot
confirm a statement, provide a detailed rational for your disagreement.
Definitions
1. AWP (Average Wholesale Price) is based on date sensitive, 11-digit NDC as supplied by
Medi-Span a nationally recognized pricing source for retail, mail order and specialty drug
adjudicated claims. AWP will be based on the actual package size used, NOT the AWP after
repackaging. Also, MediSpan will be used for the source for determining a brand vs a
generic based on MediSpan's MONY codes. This is an extremely important component of
your bid, if this cannot be agreed to then the chances of your PBM being selected will be
greatly reduced.
2. Member Copay - Members will pay the lowest of the following: plan copay, ingredient cost
plus dispensing fee, U&C, or retail cash price.
3. Rebates - Compensation or remuneration of any kind received or recovered from a
pharmaceutical manufacturer attributable to the purchase or utilization of covered drugs by
eligible persons. Rebates should be proposed with a percentage share of the total rebate
paid by the manufacturer along with a minimum floor guarantee. All rebate revenue earned
by the Client will be paid to the Client regardless of their termination status.
4. Paid Claims - Defined as all transactions made for eligible members that result in a payment
to pharmacies or members from the client or member copays (does not include reversals
and adjustments). Each unique prescription that results in payment shall be calculated
separately as a paid claim. Any per claim fees will use only paid claims as a basis for the
calculation.
5. Members - All eligible employees and their eligible dependents enrolled under the Client's
prescription benefit program.
6. Specialty Pharmaceuticals - The list of specialty drugs as defined by your PBM will be
provided to the Client as part of your response as a portion of Section V (Excel formulary).
Any future additions or deletions if you are selected to provide these services will be
communicated sixty (60) days prior to addition to the specialty drug list along with proposed
pricing.
Claims Retention and Ownership
1. The PBM agrees to provide timely and accurate claims data once a mutually agreeable
timeframe has been agreed to but no less than monthly, in the format provided in this RFP.
This data transfer requirement will be required to be a part of the contract with no
exceptions allowed.
2. The claims administrator will be required to maintain all pertinent claim records for seven (7)
years from the date of each claim payment.
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3. All claims data belongs to the client and will be made available to the Client for the life of the
contract. Including but not limited to claims level AWP, ingredient cost, NDC, GPI,
brand/generic indicator, specialty indicator, compound indicator, channel identifier, days of
supply, date of service, plan pay amount, member pay amount, dispensing fee, therapeutic
category, and the Client identifier information.
4. The Client maintains rights to claims data and will be provided all data requested within two
weeks of any such request from the Client or our designated consultant. Furthermore, the
PBM agrees to furnish monthly claims information to the Client and or its designee(s). See
Data Requirements section prior to confirming.
5. No fees may be charged to provide data less than two (2) years old.
6. The PBM shall not disclose any data, facts or information concerning services performed for
the Client or obtained while performing such services, except as authorized.
Data Integration Requirements
1. The PBM will work with any designee(s) appointed by the Client including but not limited to
third party claims administrator, data aggregators, benefit consulting firms and other entities
that may be involved with the administration of the health plan to provide up to daily
electronic exchanges of eligibility and claims information. Any and all first year setup fees
and or annual administration fees associated with any of these services must be spelled out.
2. The PBM will also provide daily/weekly/or monthly claims information to the Client, and/or
their designee(s) to help it identify the prevalent health risks within its participant population,
predict the financial impact of those risks, and target them for intervention through utilization
review, case management, and disease management services.
3. The PBM agrees to provide online, real time, claim system access to the Client, and/or their
designee(s), including access to historical claims data for up to three years following
termination of the agreement.
4. The PBM agrees to provide data integration with the selected medical vendor in order to
track shared deductibles, out of pocket maximums, and utilization management services.
The minimum frequency that data will be shared is daily.
Guarantee Requirements
1. Incremental year over year increase in the discount rate to offset inflation is highly
recommended.
2. All pricing will be effective and guaranteed for the term of the agreement and will not include
adjustments for claims volume shifts amongst the various provider channels (e.g., mail
utilization rates decline or 90-day retail utilization increases).
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