Pharmacy Benefit Managers Services

The Vendor is required to provide pharmacy benefit program (PBM), including formulary management, claims adjudication, network management, clinical programs, member and provider services, prior authorization processing, reporting, analytics, and ongoing operational support.
- PBM contractor should improve program performance through accurate claims processing, optimized drug spending, enhanced member experience, strengthened prescriber engagement, improved medication adherence, and full regulatory and contractual compliance.
- Transparent financial administration, including clearly defined pricing methodologies, rebate contracting and administration, inflation and IRA and maximum fair price (MFP)-related rebate protection mechanisms, performance guarantees, and full audit rights for agency.
- The PBM shall also support of quality improvement and value-based clinical initiatives includes medication adherence programs, high-cost and specialty drug management, opioid safety initiatives, and Medicare stars support, as applicable.
- Robust reporting and analytics shall be provided, including operational, part d metrics, financial, encounter, and regulatory reports.
- The PBM shall ensure HIPAA-compliant data security, fraud, waste, and abuse safeguards, accessible pharmacy help-desk call center services, and full audit and delegation oversight support.
- The PBM shall be responsible for implementation and transition services, including project management, systems configuration, testing, and post-go-live stabilization, and shall maintain contract terms that ensure transparency, responsiveness to regulatory changes, and transition assistance upon termination.