HR Medical Plan Admin and Pharmacy Benefit Management Services

The Vendor is required to provide the administration of medical benefits and/or pharmacy benefits for the state approximately 13,400 enrolled employees and non-Medicare retirees (or approximately 29,600 total covered members - employees and dependents).
- Medical Plan Administration
•    Provide nationwide coverage to eligible State employees, non-Medicare retirees, and their dependents (note that the State’s intent is that all participants enrolled in each of the plans offered by the State are enrolled in the same plan/product, regardless of whether they reside within or outside of the Service Area);
•    Administer and support a wellness/health program and initiatives for the active population;
•    Provide a high level of accountability around the member experience both in terms of quality care and administration;
•    Manage the finances of the medical benefit program to optimize the cost/value;
•    Improve the health of state employees and their dependents; and
•    Contribute to the state’s health policy goals around care transformation and payment reform to improve health care quality and reduce costs.
- Medicare Advantage Plan (BlueChip for Medicare Preferred)—a fully insured Health Maintenance Organization (HMO) product, including both medical and prescription drug (Rx) benefits (approximately 350 retirees enrolled),
- Medicare Advantage Plan (HealthMate Coast-to-Coast for Medicare Group Plan 14)—a fully insured PPO product with nationwide access, including both medical and prescription drug benefits (approximately 315 retirees enrolled), and
- The changes above did not apply to unions that haven’t ratified their contracts (currently approximately 2,350 subscribers or 5, 600 total members). Should there still be unions that won’t have their contracts ratified by January 1, 2027, the State’s medical administrator is expected to administer the active plans with and without these changes.
- Service Profile
•    Provision of a comprehensive national provider network with uniform quality;
•    Provision of cost-effective contracting arrangements that can be demonstrated to represent direct savings to the State and plan participants;
•    Provision of a comprehensive set of medical management services;
•    Effective, efficient, and accurate claim processing;
•    Payment of claims on a scheduled basis including issuance of reimbursement checks;
•    Provision of Explanation of Benefits (EOB) Statements (available online in addition to print copies) to patients;
•    Level 1 and 2 internal claims appeals for plan members, as well as willingness to cooperate and provide necessary documentation in the case of an external appeal;
•    Provision of best-in-class member services and customer support;
•    Accessible current coverage reports;
•    An active third-party liability (TPL) coordination of benefits (COB) function encompassing identification of TPL, cost avoidance, and collections;
•    HSA accounts administration;
•    COBRA administration;
•    Superior level of account management and service;
•    Sophisticated web-services for plan participants;
•    Capability to integrate with the State’s enrollment and open enrollment functionality;
•    Assistance in ensuring compliance with new laws and regulations.
- Pharmacy Benefit Management
- Provide a pharmacy benefit management (PBM) partner to administer the current prescription drug benefit plan designs and management programs that will meet the following objectives:
•    Provide PBM services to eligible State employees, non-Medicare retirees, and their dependents;
•    Provide a high level of accountability around the member experience both in terms of quality of care and administration; and
•    Manage the pharmacy benefit program to optimize the cost/value
- The State currently provides pharmacy benefits to eligible employees, non-Medicare retirees, and their dependents on a self-funded basis through CVS Caremark.
- State employees are eligible for coverage the first day of employment if they work 20 hours or more per week. Full-time and part-time employees have the same coverage.
- Service Profile:
•    Benefit plan set up and administration
•    Claims Adjudication
•    Ability to Integrate PBM Services with Other Vendors (e.g., Medical Health Savings Account (HSA), Utilization/Care/Disease Management), as applicable
•    Eligibility Maintenance
•    Patient and Provider Education
•    Prospective, Concurrent, and Retrospective Drug Utilization Review
•    Capability to integrate with the State’s enrollment and open enrollment functionality
•    Assistance in ensuring compliance with new laws and regulations
•    Clinical and Point Solution Programs
•    Network Pharmacy Management
•    Formulary and Rebate Management
•    Data Reporting (standard and ad-hoc reporting)
•    Distribution of ID Cards and Pharmacy Directories
•    Mail Service Pharmacy
•    Specialty Pharmacy Program
•    Complete Availability of IT services, including Online/Real Time Availability to the State and/or its Designee(s)
•    Pricing Administration
•    Member Services
•    Website with Membership Portal.