Self-Funded Medical and Pharmacy Plan Services

The Vendor is required to provide that can deliver comprehensive, cost-effective healthcare coverage for its employees.
- Provider should offer integrated medical and pharmacy benefits, including medical care, prescription drug coverage, and preventive services, supported by strong claims administration, regulatory compliance, member support, and wellness programs.
- Plan-specific copay and coinsurance calculators
- Pharmacy-specific test claim adjudication
- Clinical program information
- Online claim appeal requests
- Online Explanation of Benefits (EOB) statements
- Provide log-in for commercial participant website
- Semi-annual plan reviews to discuss trends, ongoing strategy, etc.
- Financial and participant impact modeling of clinical and utilization management programs
- Formulary modeling tools and recommendations
- This includes, but not limited to the ability to, system set-up prior to and after implementation, paid claims data, claims processing system, operation assessments, administrative fees, invoices, copay assistance programs, retail network contracts, performance guarantees, direct Rebate agreements with drug manufacturers, clinical reviews, and security as part of the annual audit at no cost when positioned
- Provide has a process for monitoring state and federal legislation, regulations and/or laws that impact pharmacy benefit services and/or Client and its members.