Pharmacy Benefits Management Services

The vendor is required to provide pharmacy benefits management (PBM) services including claims adjudication, coordination of benefits, and point-of-sale processing through the department pharmaceutical assistance program (PAP) to eligible clients who are otherwise uninsured..
- Maintain a comprehensive distribution network of pharmacies and provide reporting that meets client level data requirements of the center for medicare and medicaid services (CMS).
- Maintain a mechanism to electronically receive and provide eligibility information that matches the data requirements of administration and shall assist with formulary creation, maintenance, and revision, which shall be updated within two (2) years of activity pursuant to administration requirements; and rebate management services.
- Provide pharmacy claims management services include:
• Claims processing and adjudication on a fee per claim basis.
• Paying pharmacies for insurance co-pay and deductible costs and passing on those costs, without markup or fees, to the government for reimbursement.
• Performance reviews and participating pharmacies audits as necessary to prevent waste or fraud or as reasonably requested by government; the contractor shall report to the government any errors or improper activity detected through such audits and shall take corrective action as appropriate to prevent future errors or improper activity.
• clinical management services such as formulary management, step therapy, monitoring prior authorization requests, therapeutic duplication edits, and retrospective and concurrent drug utilization review (DUR).
• Coordination of benefits with insurance companies.
• Working with government to audit wholesale costs to ensure accurate reflection of PAP negotiated supplemental rebates from the drug manufacturers; the contractor shall additionally access rebates from the drug manufacturing companies for insured client co-pay costs.
• Recoupment services (e.g., assistance with back-billing insurances such as medicaid when coverage was retroactive).
• Collaborating with government on an approach for trend [cost] management including strong emphasis on generics.
• Meeting data analysis and PAP program-specific reporting requirements; contractor shall collect and provide client/patient-level demographic data in a format usable by government for quarterly federal reporting.
• Providing direct involvement and intervention by dedicated account management and clinical support staff that are customized to the specific needs of a small program.
• Interaction with government’s PAP-specific pharmacies and provision of advice and cooperation with case managers at identified sites, a formulary advisory committee, a public planning body, government, and other authorized officials.
• Facilitating communication between government, PAP recipients, participating pharmacies, and other authorized third persons for purposes of PBM administration.
- Pharmacy contract development & monitoring
• Online, real time claims processing of primary and secondary claims
• Contract negotiation
• Desktop & onsite pharmacy network auditing
• Plan performance review meetings: Contractor shall hold onsite plan performance meetings quarterly, to discuss opportunities to optimize the program’s performance and provide guidance on medication trends and formulary updates.
• Benefit design setup & updates: Contractor will work with the PAP staff to implement a benefit design that ensures all reporting requirements are satisfied.
- Questions/Inquires Deadline: March 21, 2025