Pharmacy Benefit Management Services

The Vendor is required to provide a pharmacy benefit management (PBM) program that prioritizes transparency, aligns incentives, and optimizes the Plan’s flexibility and control.
- The Plan's mission is to create value for the Plan’s Members and taxpayers while ensuring the sustained success of the Plan’s partners.
- The Plan is taking a principled approach to build the future of the Plan’s PBM program, not chasing the biggest rebate guarantee.
- Therefore, the next PBM contract(s) awardee(s) must provide the Plan with the following
•    Flexibility to evolve the Plan’s program as opportunities emerge,
•    Control over the Plan’s program, the Plan’s data, and the Plan’s finances,
•    Transparency as table stakes, and
•    Aligned incentives between partners, Members, and the Plan.
- The Plan aims to build a pharmacy benefit program that refuses to compromise quality, creates value for all stakeholders, leads with transparency, requires a fiduciary duty, and prioritizes building a remarkable Member experience.
- To that end, the Plan is not limiting the services to a one-partner model and wants partners that can lean into their strengths and adapt while working with others.
- To ensure clarity, the Plan vision includes the following stakeholders:
•    Plan Members;
•    North Carolina taxpayers;
•    The General Assembly;
- Pharmacists as follows:
•    Independent Pharmacists: In many of the Plan’s communities, rural pharmacists are the only accessible provider. The Plan's long-term Goal is to integrate additional clinical services into independent pharmacies, thereby creating more access points for the Plan’s Members, especially those with chronic conditions.
•    National/Regional Pharmacies: These practices are broadly distributed throughout the State and distribute many of the medications to the Plan’s Members.
•    Physician/Hospital-based Pharmacies: These practices are the Plan’s best large-scale opportunity to improve care coordination and keep care physicians based to support the Plan’s perspective on Population Health, and additional opportunities to share in the value from 340(b) programs.
- The Plan seeks a Vendor that has best in class systems and operational staff to support Plan Members. This includes the ability to process claims at retail, Mail Order, and Specialty Pharmacy point of sale.
- Because the Mail Order, specialty and utilization management (UM) may be managed by different vendors, Vendor must be able to configure UM that is provided by another entity.
- Systems must also have the online tools required to interface with providers and pharmacies. All should be interactive, secure, and with a commitment to a best-in-class user experience that can be customized by the Plan.
- Before there is a claim, there is enrollment; therefore, the Plan also seeks a Vendor with robust and flexible Electronic Data Interface (EDI) capabilities.
- The Plan has both Non-Medicare primary and Medicare-Primary Members. These Members are not segregated by Group.
- There shall also be ongoing claims and financial audits to ensure claims are paid based on the Plan Design and Formulary in place at the time the claim was incurred.
- Must be willing to collaborate with, provide data to, and respond promptly to other vendors supporting the Plan.
- Transparency in all aspects of the relationship which includes disclosing all contractual relationships that will or may impact the Plan and providing internal documentation, processes, data, or other information, as requested by the Plan.
- The Account Manager shall be accountable for ensuring all projects are tracking and all definitions are owned by the Plan, as well as owning socializing those definitions between all partners of the Plan.