Pharmacy Benefits Management Services

The Vendor is required to provide pharmacy benefits management services for the administration and management of the state’s employee insurance programs and retirement systems.
- A comprehensive drug utilization review program that is based on the highest quality comparative effectiveness research, as well as lowest net cost objectives, and includes dose and quantity limits, and concurrent, prospective, and retrospective therapeutic drug monitoring with the objectives of: minimizing the risk of adverse drug interactions or drug-induced illness; increasing use of drug therapies that are medically necessary and most clinically and cost effective; minimizing the risk of over utilization of medications; identifying individual prescribers and/or pharmacies that demonstrate patterns of possible misuse; and promoting cost effective drug therapies 21 in accordance with national prescribing guidelines.
- The drug utilization review program shall include an opioid management program that promotes patient safety by ensuring appropriate prescribing of opioids and is compliant with both federal and state guidelines.
- Maintain its drug utilization review program to be current with the market and current literature, and to be consistent with agency strategic goals. The Contractor shall proactively implement new programs and/or strategies as market and trend conditions dictate.
-A system of coverage reviews for selected medications, including the use of step therapy algorithms based on national prescribing guidelines that require trials on less expensive yet equally clinically effective alternatives prior to prescribing more expensive drug therapies.
- Market, develop, organize, implement, operate and maintain a network of participating pharmacies (the “pharmacy network” or “network”); while agency understands that contracts are between the agency and pharmacies, the agency must work toward maximizing participation to ensure a successful and robust network.
- The contractor shall contact all retail pharmacy chains, -defined locally owned independent pharmacies and nursing home pharmacies operating in south carolina to solicit their participation in the pharmacy network; agency desires the maximum participation by all willing pharmacies, whether independent or national chain, and the greatest geographical coverage for the network within the state, including rural areas.
- The contractor shall extend the opportunity of network participation to any willing retail pharmacies and pharmacy chain stores located in other states to enable state health plan members who work or reside outside the state to have access to the pharmacy network.
- The contractor shall provide representatives to make personal contact with the pharmacy provider community to communicate plan rules, benefits, changes and claims filing procedures, as well as related pharmacy issues; all material distributed to providers is subject to approval by agency insurance policy and communications departments.
- The contractor or its subcontractor shall provide home delivery pharmacy services; any program to encourage use of the home delivery shall not be implemented by the contractor without the express approval of agency executive director or their designee(s).
- The contractor or its subcontractor shall allow for full-service dispensing of medications by south carolina based locally owned independent pharmacies that have earned or are in the process of earning accreditation as a specialty pharmacy by an acceptable accreditation body, as well as pharmacies it owns or operates; members in the commercial plan are required to purchase specialty medications at a specialty pharmacy network pharmacy.
- The contractor shall offer a retail maintenance pharmacy network, similar in respects to the retail maintenance networks currently in place, that allows members in the commercial and agency plans options to purchase 90-day supplies of prescription drugs at local retail pharmacies for the same copayment available through the home delivery pharmacy; members in the savings plan pay the full allowed amount for prescription drugs.

- Contract Period/Term: 1 year