Pharmacy Benefits Manager Services

The Vendor is required to provide pharmacy benefits manager (PBM) services to manage its prescription program for its active and retired employees effective on January 1, 2027.
- General requirements
•    Executed company strategy and programs focused upon bridging the gap of healthcare inequities, and the social determinants to quality care. 
•    Work collaboratively with other providers, i.e. Medical and, disease 
•    Management to measure effectiveness of the city formulary strategies and health outcomes. 
•    Effective management of new pharmacy programming initiatives such as glp1’s etc. 
•    Pipeline monitoring and approval 
•    Ability to manage a narrow network if required 
•    Eligibility maintenance id card production and distribution 
•    Electronic and paper claim processing and payment
•    Utilization management strategy consistent with protocols associated with prior authorization, step therapy, quantity limits, and the health and safety of the enrollees. 
•    Specialty management, accumulators and maximization policy (disclose and seek plan sponsor approval), copay assistance coordination, transparency and reporting 
•    Developing and maintaining “mac” list utilization review contracting with and auditing of pharmacies 
•    Overseeing all aspects of the mail order pharmacy 
•    Negotiating discounts and rebates with drug manufacturers 
•    Management and transparency related to 340b drug distribution and the impact on rebates 
•    Implementing cost-containment measures, including condition management, adherence and gaps in care.
- Service requirements
1. Member services related:
•    Multi- lingual support from customer service representatives, communication materials and website;
•    Respond to employee appeals, complaints or grievances;
•    Toll-free telephone and fax service provided to members;
•    Plan set-up and maintenance including installation;
•    Maintain up-to-date on-line policy data to support compliance with legislative changes, ADA; (as appropriate), efficient claim processing, member services, internal and client reporting
•    Administer the prescription drug program in accordance with federal law and where applicable, state law;
2. Eligibility:
•    Successful applicant will accept the city’s eligibility determination.
3. Claims processing:
•    Successful applicant will process all claims incurred prior to termination following contract termination (if it occurs).