Pharmacy Benefit Manager System

The government authority in Washington, DC is seeking a vendor to provide a Pharmacy Benefit Manager System (PBMS) delivered as a Software-as-a-Service (SaaS) solution. This system will support the Medicaid Fee-for-Service (FFS) program and is expected to cover comprehensive pharmacy benefit management functions, including the adjudication of valid pharmacy drug claims, the management of pharmacy and prescribing provider networks, and the administration of designated District functions.

The PBMS must include robust beneficiary and provider relationship management services, such as support for a call center, toll-free numbers, help desks, automated call systems, and a web portal. Additionally, the vendor is required to provide essential support services, including problem resolution and escalation, staff training, and detailed reporting mechanisms. The system will integrate with the District’s Department of Human Services case management platform and facilitate coordination with third parties responsible for fund recovery activities, such as casualty, health insurance, absent parent, estates, and third-party cost avoidance. The solution should also encompass Medication Therapy Management Services to improve patient health outcomes.