The Vendor is required to provide and manages the enrollment and applications to hundreds of third-party prescriptions plans so that the department pharmacy can adjudicate claims for prescription third party payments.
- Provide management for all Medicare D payers, including rate negotiation, claim inquires and credentialing.
- They shall house ERA (electronics remittance advices) in a secure location accessible by members with a unique ID and vendors providing supplies and services in the healthcare and pharmaceutical industry.
- Contract administration:
• Create and manage contracts for pharmacy services.
• Conduct negotiations with pharmacy benefit managers (PBMS) and wholesalers to secure favorable pricing and terms.
• Ensure contracts comply with state and federal regulations, including but not limited to:
- Compliance monitoring:
• Monitor compliance with all federal and state pharmacy benefit regulations.
• Conduct regular audits of prescription drug claims to ensure correct payment and utilization.
• Develop and implement corrective action plans for non-compliance findings.
- Pharmacy benefit design:
• Assist district in designing pharmacy benefit plans that promote the appropriate, safe, and cost-effective use of medications.
• Implement formulary management strategies and prior authorization protocols to enhance quality while controlling costs.
- Claims processing:
• Provide claims processing services, ensuring accuracy and timeliness in adjudicating pharmacy claims.
• Ensure integration with existing state health information systems to streamline operations.
• Maintain detailed records of claims data for performance analysis, financial forecasting, and reporting purposes.
- Data analytics and reporting:
• Provide performance analytics related to pharmacy utilization and spending.
• Prepare and submit quarterly and annual reports on pharmacy trends, savings, compliance, and outcomes.
• Implement an electronic reporting dashboard for district stakeholders.
- Contract Period/Term: 5 years
- Questions/Inquires Deadline: June 13, 2025