Pharmacy Benefit Management Consulting Services

The Vendor is required to provide for a Pharmacy Benefit Manager (PBM) from qualified consulting firms who have experience and expertise working with large state governmental subdivisions on financial and actuarial analysis of Health Insurance and Pharmacy benefits.
- Consultants should have substantial experience in the design, procurement, and implementation of large-scale1 pharmacy benefit plans including clinical, financial, and operational perspectives.
- Following implementation of the PBM effective July 1, 2026, ongoing services will include strategic advisement, continuing industry education, performance oversight, and vendor management.
- The prescription drug benefits for these conventional health plans are carved out, on a self-insured basis, through a direct contract with a pharmacy benefit manager (PBM).
- The pharmacy benefit plan design is structured around a three-tier member co-payment arrangement, with different copayments for generic, brand name formulary, and brand name non-formulary medications.
- The PBM consultant services will require coordination and data sharing with the City’s current health benefit consultant and existing health insurance carriers and pharmacy benefit manager.
- Strategic Advisement
• Provide ancillary support to address any issues between City and selected PBM.
• Review and advise on new pricing models, products, programs, and services as they are introduced into the market by PBM, pharmaceutical manufacturer, or other pharmacy related vendors leveraging industry expertise and exposure.
• Manage all aspects of statement of work and provide guidance related to any audit findings.
• Attend ad-hoc conference calls to address concerns or share industry best practices.
• Provide white papers related to industry hot topics and new medications.
• Review PBM program ROI methodology and provide input and guidance to the City.
- Provide ongoing support including contract negotiation, implementation, clinical and plan analysis and recommendations including KPIs to track plan performance.
- Manage and actively participate in the PBMs market check analysis and performance guarantee process and advise city staff on actions required.
- Provide the City with ongoing expertise in prescription drug benefits and trend management, playing an active role in monitoring and evaluating the impact of the City’s benefits and strategic initiatives.
- Conduct periodic data mining and analytics to identify claims anomalies and track noteworthy developments that impact the City’s bottom-line, such as: patent expirations and new drug releases, drug price inflation spikes, compound drug expenditures, and potential instances of fraud, waste, and abuse.
- Assist in the annual rate renewal process to create prescription drug premium rates for each of the City’s health plan(s) and advise city staff on appropriate funding levels for purposes of self-insured premiums and annual City budgets.