Pharmacy Benefit Management Services

The Vendor is required to provide the city provides an in-house full service pharmacy for plan members, select retirees, and members on the city health plans.
- Medical Plan Administration, Medical Network and COBRA administration services are being marketed separately and are presently underway.
- The current TPA, AmeriBen, administers an Anthem BC/BS PPO network through a Jointly Administered Arrangement (JAA) for the City.
- AmeriBen is the COBRA administrator for medical/Rx, dental, vision and EAP services.
- AmeriBen provides utilization review, case management and health management services.
- As mentioned previously, the city has an employer sponsored health on-site clinic with care provided by nurse practitioners through the university, city that provides primary and acute care, health management, and wellness services for employees, retirees and dependents on the health plan of the city.
- The list of services provided by the current PBM, VytlOne, for the in-house pharmacy and disease management programs is outlined in the next section. Any proposal would need to perform similar services on the City’s behalf.
- The primary factors include pricing, pharmacy network access, formulary management and formulary disruption, contractual compliance, account management services, reporting capabilities, financial stability, performance guarantees, flexibility, references, clinical programs, and customer service.
- Clinical Program Management
• Formulary development, maintenance, and optimization (including custom formulary options)
• Clinical review committee governance and employer participation options
• Utilization management programs:
o Prior authorization
o Step therapy
o Quantity limits
• Specialty drug management programs
• Biosimilar adoption strategy and management
• High-cost drug management (e.g., gene therapies, cell therapies)
• Drug pipeline monitoring and impact forecasting
• Clinical program performance reporting and outcomes measurement
• Evidence-based clinical policy updates and communication
- Network & Pharmacy Management
• Retail pharmacy network contracting and management
• Mail order pharmacy services (90-day supply programs)
• Specialty pharmacy network and distribution
• Coordination and collaboration with In-House Pharmacy
• Pharmacy network disruption management and transition support
• Clearly communicated access standards (geographic coverage, rural access, etc.)
• Transparent pharmacy reimbursement methodologies and guarantees
• Network performance monitoring (cost, quality, access)
- Claims Processing & Adjudication
• Real-time claims adjudication capabilities
• Coordination of benefits (COB) functionality
• Eligibility file integration and management
• Accumulator and maximizer program administration
• Copay calculation and benefit application accuracy
• Formulary enforcement at point of sale
• System uptime guarantees and performance standards
• Disaster recovery and business continuity planning
- Specialty Pharmacy Management
• Specialty drug distribution model and network design
• Care management and patient support programs
• Clinical outreach and adherence programs
• Site-of-care optimization strategies
• White bagging / brown bagging capabilities
• Specialty drug cost containment strategies
• Coordination with medical benefit (if applicable)
• Reporting on specialty utilization, trend, and outcomes
- Plan Design & Strategy Support
• Plan design consulting and modeling
• Copay / coinsurance strategy development
• High-performance formulary options
• Alternative funding program integration (e.g., copay assistance optimization)
• Clinical and financial impact modeling of plan changes
• Benchmarking against peer groups and industry standards
• Multi-year pharmacy strategy development
- Implementation & Transition Support
• Implementation timeline and project management
• Eligibility and data migration
• Formulary transition management
• Member disruption mitigation strategies
• Communication plan for members and stakeholders
• Training for HR and benefits team
• Go-live support and stabilization period services.