Medical Administrative Services Only and Pharmacy Benefits Manager Services

The vendor is required to provide for medical administrative services only (ASO) with integrated pharmacy benefits manager (PBM) services for our self-funded health plan, emphasizing cost efficiency, service excellence, and access to a robust PPO network.
- Include a clear implementation timeline, transparent pricing with performance guarantees, and innovative, customizable solutions to enhance member experience and cost efficiency.
- We seek a partner capable of delivering high-quality, data-driven services with a focus on network accessibility and financial accountability.
- General information
• Standard industrial classification (sic): 9199, government
• Cohort: 11,869 enrolled individuals (5,341 contracts; and 6,528 dependents) with claims totaling $109m for plan year 1/1/24 to 12/31/24; includes twenty-two union groups, approximately 80% of population, with multi-year agreements and four-year rolling benefits ratification clause
• Definition of eligible: full-time employees and their eligible dependents, including individuals deemed eligible per a union collective bargaining agreement; retired police, deputy sheriffs, and correctional officers
• Plan year: January 1 – December 31
- Objectives
• Cost efficiency: secure competitively priced ASO with integrated PBM services to optimize the financial performance and promote the sustainability of the self-funded health plan, while maintaining quality care.
• Service excellence: vendor capable of delivering high-quality administrative and pharmacy benefit management services to ensure operational efficiency and member satisfaction.
• Transparency: achieve full visibility into medical and pharmacy claims processes, drug pricing, rebates, and performance metrics to support informed decision-making and accountability.
• Robust network access: provide a geographically comprehensive PPO network for medical services and a broad pharmacy network (retail, mail-order, specialty) with competitive discounts.
• Cost containment: leverage PBM strategies such as formulary management, prior authorization, and generic substitution to control prescription drug costs while maintaining clinical efficacy.
• Data-driven insights: obtain regular, detailed reporting with real-time access to medical and rx claims data, utilization metrics, and trends.
• Performance accountability: establish measurable service standards (e.g., claims accuracy, processing times) with performance guarantees.
• Flexibility and innovation: enable customization of services (e.g., wellness programs, stop-loss integration) and adoption of innovative solutions to meet evolving needs.
- Specifications
• Claims administration: process, adjudicate, and pay claims in accordance with plan design, provider contracts, and applicable regulations, ensuring high accuracy and timeliness.
• Network management: provide access to a broad preferred provider organization (PPO) network, including primary care providers, specialists, and facilities, with sufficient geographic coverage to meet member needs. provide a broad pharmacy network (retail, mail-order, specialty).
• Utilization management: administer prior authorizations, case management, and other utilization review programs to optimize care delivery and control costs.
• Customer service: offer responsive support addressing member inquiries, claims issues, and appeals promptly and effectively.
• Reporting and analytics: deliver regular, detailed reports (e.g., monthly claims, utilization trends) and real-time data access to support plan oversight and strategic decision-making.
• Implementation: execute a seamless transition from the current vendor, including data migration and employee communication, within an agreed timeline.
• RX transparency: disclose drug pricing, earned rebates, and administrative fees, ensuring full visibility into financial arrangements.
• Performance standards: meet defined performance guarantees (e.g., claims accuracy, service response times) with accountability measures such as penalties or credits.
• Integration: integration with existing benefits administration system for purposes of transmitting eligibility information and demographic updates; and integration with advanced data analytics system claims and eligibility data transmission on a weekly basis.
- Contract Period/Term: 3 years
- Questions/Inquires Deadline: April 25, 2025