Pharmacy Benefit Management Services

The Vendor is required to provide Medicare pharmacy benefit management services for large municipalities and state governments with similar experience in depth in the private sector.
- The organization must have prior experience directly related to the services requested in this RFP and be able to demonstrate clearly its ability to:
•    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 committee.
- Requirement:
•    Prescription claim adjudication.
•    Participant enrollment maintenance including the capability to accept and process enrollment files from the medical third-party administrators’ (TPAs) 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/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.