Pharmacy Benefit Management Consulting Services

MetroPlusHealth is seeking consultant services specializing in Pharmacy Benefit Management (PBM), to provide strategic, operational, financial, clinical, and regulatory expertise related to both pharmacy benefit and medical benefit drug management programs.

The selected vendor will support MetroPlusHealth’s evaluation, optimization, oversight, and long-term strategic planning of pharmacy and provider-administered drug benefits across all lines of business.

The vendor will assist MetroPlusHealth in maximizing the clinical and financial value of its pharmacy and medical drug programs by identifying and evaluating cost-saving opportunities, strengthening vendor performance and accountability, monitoring financial and operational performance, and providing actionable recommendations for program improvement. The vendor will also support ongoing market and industry benchmarking to help ensure MetroPlusHealth's programs, pricing, contractual arrangements, and overall pharmacy strategy remain competitive and aligned with evolving market conditions.

The selected vendor will serve as a strategic advisor to MetroPlusHealth and provide independent expertise to support the evaluation, optimization, oversight, and long-term strategic management of MetroPlusHealth’s pharmacy benefit and medical benefit drug programs across its lines of business.

Annual Market Check and Benchmarking Services

Annual PBM and pharmaceutical market assessments will be performed to ensure MetroPlusHealth’s competitiveness and identify opportunities for financial, operational, and clinical improvement. Services shall include:

• Conduct annual market checks of PBM pricing, rebate guarantees, dispensing fees, specialty pharmacy arrangements, and contract performance standards.
• Benchmark PBM pricing against national and regional healthplan peers, including Medicaid, CHP, Medicare Advantage, Marketplace/Qualified Health Plans and Commercial Managed Care as applicable.
• [...]
• Provide ongoing market intelligence regarding PBM trends, pricing developments, contracting strategies, regulatory developments, and other changes that may materially impact MetroPlusHealth.

Pharmacy Financial and Trend Analysis

The consultant shall provide ongoing financial analysis and reporting to assist MetroPlusHealth in managing pharmacy expenditures and identifying opportunities for improvement, including:

• Analyze pharmacy and specialty drug utilization and cost trends.
• Evaluate actual PBM financial performance against contracted pricing and guarantees.
• Analyze rebate and other manufacturer-derived revenue performance and reconciliation.
• [...]

Additional Deliverables

At a minimum, the consultant shall provide:

• Annual PBM Market Check Report.
• Annual PBM Benchmarking Assessment.
• PBM Strategy Recommendations.
• Quarterly Pharmacy Financial and Trend Reports.
• Annual Medical Benefit Drug Management Assessment.
• Strategic Roadmap for Pharmacy and Medical Drug Optimization.
• Annual mock audit support (i.e. CMS Mock Audit, Article-44 Mock Audit) related to utilization management and claims adjudication.

PBM Performance Management

• Review and evaluate PBM contract terms and financial arrangements.
• Assess pricing guarantees, rebate performance, and contractual compliance.
• Conduct periodic PBM performance audits and identify opportunities for improvement.

Proposers shall submit a complete Proposal Package in electronic format no later than the date and time specified in the RFP Timeline. Proposals must be **submitted by email** to the individual designated on the first page of this RFP. The complete Proposal Package, including all attachments and exhibits, shall not exceed twenty (20) megabytes in total file size unless otherwise approved by MetroPlusHealth in writing.

Substantive questions regarding the Scope of Work or any aspect of this RFP must be submitted by email to the individual designated on the first page of this RFP. Emails submitted regarding this RFP must include the RFP Number, as identified in this document, in the subject line.

**Minimum criteria (required):** The proposer must provide a signed attestation confirming compliance with all Minimum Qualifications identified in this RFP. The proposer shall provide a minimum of three (3) references from current or former health plan clients for whom similar services have been performed.

Evaluation Criteria

| Category | Weight % |
| --- | --- |
| Quality of proposed approach and adherence to SOW | 20% |
| Relevance of quality of experience | 30% |
| Technical Capabilities | 20% |
| Cost | 20% |
| MWBE Utilization Plan or MWBE Status | 10% |

The term of the contract resulting from this RFP shall be 3 years with 2 one-year renewals.