6-Mandatory Minimum Requirements - Medical and PBM Providers.xlsx

This file is a checklist of mandatory minimum requirements for medical and pharmacy benefit management (PBM) providers responding to a Request for Proposals issued by the Purchasing Department of a Utah school district (PCSD). The RFP seeks Group Medical and/or Pharmacy Benefit Management Services effective September 1, 2026, with an initial contract term of three years and options to extend for up to two additional one-year periods, followed by potential year-to-year renewals for up to five additional years. The district currently operates under a self-funded model administered by UnitedHealthGroup, with UMR as the medical third-party administrator and Optum Rx as the pharmacy benefit manager. The procurement may result in multiple contract awards in one of three formats: combined medical and PBM services, medical administration only, or PBM services only, with awards determined by responsive and responsible vendors achieving the highest scores.

The mandatory minimum requirements establish specific qualifications and commitments required of all bidders. Medical providers must be licensed in Utah, demonstrate capability in administering self-funded public-sector plans, maintain HIPAA and privacy regulation compliance, provide eligibility exchange with Employee Navigator, coordinate claims data with the selected PBM, offer a Utah-based or regionally accessible account manager, participate in claims repricing, guarantee rates for three years, provide administrative renewals 210 days prior to renewal, submit monthly medical claims data feeds to Cedar Gate Technologies, attend annual benefit fairs, draft Summary Plan Descriptions, accept the current plan design, and coordinate with a designated stop loss carrier. PBM requirements include URAC accreditation, Utah licensure, financial transparency with clear rebate disclosure, NCPDP claims feeds and accumulator data provision, participation in RingmasterRx repricing, three-year rate guarantees, renewals available 180 days prior to contract renewal, and ongoing monthly pharmacy claims data feeds to Cedar Gate Technologies.