T2679 - Employee Benefits: Pharmacy Benefits Management

The Contractor shall establish and maintain a retail pharmacy network, a retail pharmacy 90-day network, a mail order pharmacy, and a specialty pharmacy. The Contractor shall administer clinical programs including controlled substance excessive use management, drug utilization review, medication adherence, prior authorization, quantity limit, step therapy, dose optimization, mandatory generic, mandatory mail order, copay and accumulator maximizer, and other programs. The Contractor shall provide member and client management services including account management, customer service, web services, and benefit coverage and plan design administration. The Contractor shall manage eligibility and enrollment, including open enrollment, identification cards, technical interface with the State and online enrollment vendor, and coordination with SHBP/SEHBP vendors. The Contractor shall provide extensive reporting including general data reporting, EGWP reporting, quarterly enrollment summary reports, periodic reporting, additional reporting, renewal reporting, and financial reporting. The Contractor shall administer claims, including claims adjudication, subrogation, and fraud, waste, and abuse detection. The Contractor shall adhere to pass-through pricing with guarantees for ingredient cost discounts, dispensing fees, rebates, and specialty drug pricing. The Contractor shall implement the contract within a six-month mobilization period and comply with extensive data security requirements.