The vendor required to provide pharmacy benefit management (PBM) to prescription drug benefit administration and clinical management services for the agency, including but not limited to, the following:
• Network administration: establish, maintain, and manage retail, specialty, and mail-order pharmacy networks; ensure adequate access, credentialing, and performance oversight.
• Claims processing and adjudication: real-time claims adjudication; eligibility file management; coordination of benefits; prior claim reversals and adjustments; fraud, waste, and abuse monitoring.
• Formulary and utilization management: develop and manage formularies; implement prior authorization, step therapy, quantity limits, and other utilization controls aligned with plan sponsor direction.
• Clinical programs: provide clinical interventions and cost-management programs.
• Specialty and high-cost drug management: specialty pharmacy services and care management; limited distribution drug handling; management of manufacturer programs; outcomes reporting.
• Rebates and financial management: negotiate manufacturer rebates and other revenue; administer and remit rebates per contract; provide full transparency and audit support; ensure pass-throughs as required.
• Member and provider services: member support pharmacy help desk; communications for formulary changes, pa requirements, and benefit updates.
• Reporting and analytics: provide standard and ad hoc reporting, dashboards, and data extracts (including claims detail); support performance guarantees and reconciliation.
• Implementation and ongoing account management: project management for implementation, testing, and go-live; ongoing account management, issue resolution, and plan design support.
• Compliance and data security: maintain privacy compliance, required certifications, and data security controls; support audits and regulatory reporting as applicable.
- Contract Period/Term: 1 year
- Questions/Inquires Deadline: January 19, 2026
