The vendor required to provide pharmacy benefit management (PBM) services specifically for workers’ compensation claims.
- Comprehensive PBM solution that includes:
• A robust national pharmacy network ensuring injured employees have access to prescription services 24/7.
• Efficient processing and adjudication of pharmacy charges.
• Implementation of a drug utilization review program.
• Reduction of annual pharmacy costs beyond the state workers’ compensation fee schedule.
• Streamlined administrative processes to reduce time and effort for city staff.
- Pharmacy bill reduction
• Pricing compliance: detail the measures your organization takes to ensure prescription pricing remains within or below the state fee schedule.
• Paper bill processing: explain your process for handling paper bills submitted by pharmacies or third-party billers.
• Out-of-network capture: describe your methodology for identifying and managing prescriptions filled outside of your pharmacy network.
• Compound medications: outline your approach to reviewing, approving, and pricing compound medications.
- Specialty drugs:
• Price negotiation commitment: directly with manufacturers or wholesalers to secure pricing for cancer-related medications at or below the manufacturer’s list price or wholesale acquisition cost (WAC), inclusive of all applicable discounts, rebates, or other cost-reduction mechanism.
• Billing methodology: the offeror utilizes actual acquisition cost (AAC) billing when it results in a lower cost to the city than the state workers’ compensation fee schedule.
• Cost-saving innovations:
o Rebate optimization programs
o Outcomes-based pricing models
o Patient assistance programs
o Specialty drug carve-outs or alternative funding solutions
- Custom formulary:
1. Formulary development process:
• The roles and responsibilities of clinical staff, pharmacists, and client representatives.
• The city’s medical director and workers’ compensation coordinator will be incorporated.
• The timeline and methodology for initial formulary creation.
• Any tools or systems used to support formulary design and customization.
2. Formulary review and adjustment intervals:
• The frequency of reviews (e.g., quarterly, biannually).
• The criteria used to determine necessary changes.
• Stakeholders are notified and involved in the review process.
3. Individualized formulary adjustments:
• The process for requesting and approving such adjustments.
• The role of the prescribing physician and the city’s clinical team.
• Any limitations or exclusions that may apply.
4. Electronic adjustment capabilities: explain whether the city’s workers’
• The platform or system used to manage formulary changes.
• User access levels and security protocols.
• Reporting and audit capabilities related to electronic adjustments.
- Authorization and first fill:
1. Adjuster authorization timeframe:
• The standard timeframe (in hours or business days) required to obtain adjuster authorization for prescription fills.
• Include any expedited processes available for urgent cases.
2. Communication with injured employee:
• When initial contact is made with injured employee following claim initiation.
• The communication channels used (e.g., phone, email, SMS, mail).
• Written information: confirm whether written materials outlining PBM services are provided to injured employees.
• Include sample documents or describe the format and delivery method.
3. Card issuance program:
• Outline your process for issuing pharmacy benefit cards to injured employees.
• Include details on:
o Timing of card issuance (e.g., upon claim initiation, post-authorization).
o Card format (physical, digital, or both).
o Activation procedures and instructions provided to employees.
4. Risk assumption for unauthorized prescriptions:
• Clarify whether the offeror assumes any financial or operation risk for prescriptions filled without prior authorization.
• If applicable, describe safeguards in place to minimize unauthorized fills and how disputes or reversals are handled.
- Data system requirements:
1. System integration:
• Offeror shall demonstrate the ability to interface seamlessly with the city’s workers’ compensation claims management system, origami risk, at no additional cost to the city.
• Integration must support real-time data exchange and ensure system compatibility.
2. Daily claims loading:
• Offeror shall implement a method to load claims into its system on a daily basis to ensure timely prescription fulfillment for injured employees.
• The process must support automated updates and minimize delays in pharmacy access.
3. Electronic data transfer:
• Offeror shall ensure that pharmacy invoice and claim data— including but not limited to claim details, payment information, and pharmacy invoice images—are electronically transferred to and from the city’s claims management system.
• Data exchange must be secure, auditable, and compliant with applicable privacy regulations.
4. Pharmacy billing management:
• Offeror shall receive electronic billing from participating pharmacies and maintain the capability to identify and track duplicate billing, service dates, original bill amounts, and recommended reductions.
• The system must support automated flagging and reconciliation of discrepancies.
5. Payment transfer file:
• Claim number
• Claimant name
• Date prescription was filled
• Prescribing provider’s name
• Medication name, dosage, and quantity
• Invoice charges
• Reductions applied
• Final allowance amount
- Data system and reporting requirements:
• Maintain a robust data system capable of implementing and monitoring cost containment strategies and utilization review protocols to ensure optimal management of pharmacy benefits.
• Provide the city with on-demand access to ad hoc reporting tools that allow for customizable data queries and real-time analytics.
• Deliver comprehensive reports on a monthly, quarterly, and annual basis.
- Contract Period/Term: 5 years
- Questions/Inquires Deadline: January 27, 2026
