Pharmacy Benefit Management Services

The vendor is required to provide pharmacy benefit management partner for prescription drug benefit services effective July 1, 2026, with minimal disruption in member experience and clinical oversight.
• Offer state of the art prescription drug benefit management services;
• Provide clinically and financially appropriate management programs;
• provide transparency in contracting terms with drug manufacturers, drug distributors, including wholesalers, pharmacy services administrative organizations, and pharmacy networks for both traditional and specialty drugs;
• Provide competitive financial terms;
• Provide excellent customer service to participants;
• Provide excellent account management services to the state, including timely reporting;
• Meet or exceed performance guarantees; and
• Be responsive to requests of the agency.
- Participant enrollment maintenance including the capability to accept and process enrollment files from the medical benefit partners’ (currently Highmark and Aetna) designated format.
- Comprehensive management of the medicare part d employer group waiver plan (EGWP) including the ability to maintain benefits for medicare retirees who are awaiting their EGWP enrollment approval by the centers for medicare and Medicaid services (CMS).
- Patient and provider education.
- Network pharmacy management, including a 90-day retail network.
- Formulary management and rebate administration.
- Systematic prospective, concurrent, and retrospective drug utilization review.
- Clinical management programs including prior authorization and appeals processing.
- Fraud, waste, and abuse detection and prevention programs.
- Mail order and specialty pharmacy services.
- Dedicated, knowledgeable, and accessible member support services.
- Secure and multifunctional member website that allows convenient access to enrollment and plan information.
- Meaningful and timely management reporting.
- Integration with the state’s medical and wellness programs and providers for utilization, care and disease management, medical health savings account (HSA), as applicable.
- Dedicated, expert, and accessible account management staff.
- Support for all program related member communications including open enrollment, direct mailings, and other types of media.
- Superior program implementation support.
- Provide rebate reporting by individual drug and drug class can be shared on all drugs and drug classes
- Actively and proactively engage in cost savings conversations and programs to lower prescription pricing.
- Contract Period/Term: 1 year
- Mandatory Pre-Proposal Meeting (Conference Call) Date: August 25, 2025
- Questions/Inquires Deadline: August 27, 2025
- Intent to Submit Proposal Deadline: August 22, 2025