Pharmacy Benefit Management Services

The Vendor is required to provide pharmacy benefit managers (PBMs), to administer the existing pharmacy program.
- Requirement:
•    Reduce or eliminate cost trends in future years by delivering a transparent, innovative program that maximizes cost savings and improves clinical outcomes for the county and its covered employees and dependents. 
•    Address the cost spiral in specialty medications from a use and unit cost perspective. 
•    Deliver a stable formulary that carefully balances rebates and lowest net cost and is updated as appropriate with sufficient notice of changes to the county, covered members, and affiliated providers. 
•    Demonstrate the ability to explore and evaluate alternative methods for accessing prescription drugs to identify options that achieve the lowest net cost for the plan. 
•    Provide monthly claims extracts as needed for the county’s vendor partners and ensure a fully integrated data reporting system compatible with the county’s systems, third-party administrator (TPA) (currently allegiance benefit plan management), local physician hospital organization, (currently community health partners (CHP)), and benefits consultant and actuarial
•    This integration should facilitate a comprehensive understanding of claims utilization and disease management. 
•     the vendor must collaborate with the county’s TPA, and other entities involved in health plan administration to enable seamless, daily electronic exchanges of eligibility information and regular claims data transfers (at least weekly). 
•    Demonstrate the ability to provide at least the current level of cost management processes (i.e. Ability to administer a therapeutic maximum allowable cost (mac) for proton pump inhibitors (PPIS), step therapy, generic substitution, concurrent drug utilization management, over the counter (OTC) programs, co-pay assistance programs etc.) 
•    Provide a structured program to assist the county and CHP in addressing potential abuse or diversion of narcotic medications, such as oxycodone. 
•    Demonstrate the ability to implement new innovative programs to address opportunities that are uncovered through the ongoing analysis of both medical and pharmacy claims (for example, the ability to administer a therapeutic mac for specific classes of medications such as (PPIS) and non-sedating antihistamines). 
•    Provide a robust quarterly reporting process that evaluates the plan’s financial performance, identifies key cost drivers, and assesses the effectiveness of cost management programs. 
•    Reports should include actionable insights and recommendations to mitigate cost drivers while benchmarking the county’s plan performance against prior periods, the vendor’s overall book of business, and other public entity employers.
•    The vendor must be responsive to the county’s evolving needs, adjusting reporting as required. Quarterly meetings should be conducted in person and aligned with county meetings to ensure strategic collaboration and discussion. 
•    Provide specific communication support to reinforce current programs, for example, co-pay programs, weight loss, diabetes as well as new ones that may be implemented in the future. 
•    Provide a seamless retail and mail order process that is user-friendly to both employees and physicians.
•    The county would like to explore the use of group purchasing organization (GPO) pricing for selecting medications, where a separate class of trade makes economic sense for the county. 
•    The main financial and strategic objectives to be attained are:
o    Manage prescription drug costs, including specialty drug spending, while ensuring employees, spouses, and their dependents experience a seamless transition with administration as effective as the current program.
o    Minimize plan costs and optimize member access to GPO pricing for selected medications. 
o    Ensure transparency and cost-effectiveness by requiring full pass-through of rebates with a guaranteed minimum rebate and the option for full pass-through pricing, with rebate guarantees based on all drugs, not just those with obtained rebates. 
o    Actively control drug costs by promoting the use of generics and over-the-counter alternatives while resisting pharmaceutical manufacturers' emphasis on higher rebates over true cost savings and patient outcomes. 
o    Build a strong, collaborative approach with all stakeholders, including the county, its consultants, community health partners (CHP), and local providers, to effectively manage pharmacy costs and improve patient outcomes. 
o    Work closely with CHP to coordinate special programs, facilitate system access for clinical overrides, and educate local providers. 
o    Provide access to detailed pharmacy data that integrates with medical claims data to identify cost drivers and enhance cost management. 
o    Demonstrate processes that work to detect and prevent fraud and abuse at both the individual and pharmacy levels. 
o    Place an onsite representative, either part-time (example: Mon & Thurs 8-12; Wed & Fri 1-5 or full-time (example: Mon-Fri 8 am-5 pm), to provide dedicated support for pharmacy-related issues. 
o    Engage with participants and physicians to encourage acceptance of and compliance with cost-saving measures.
- Claims record retention and transfer
•    Required to maintain all pertinent claim records for seven (7) years from the date of each claim payment.
•    In the event of termination, the prescription drug administrator must agree to transfer to the county (or another party as designated by the county) within thirty (30) days of notification, all required data and records necessary to administer the plans. 
•    This data would include, but not be limited to, the following:
o    List of covered employees and dependents, 
o    Preauthorization information for specific medicines, 
o    Records or hard copy of claims transaction data as designated by the county, 
o    Current mail-order prescriptions.
•    No fees may be charged to provide data less than two (2) years old.
•    It is expected that contracts, necessary administrative forms, administrative manual, employee communications, prior authorization transfer data, and other materials will be prepared as quickly as reasonably possible.
•    Provide an appropriate timeline for implementation. 
•    The chosen vendor will be expected to bear the cost of installation of appropriate administrative systems, contract preparation, billing, network enhancements, related administrative manuals, enrollment forms, and communication with employees and providers.