Pharmacy Benefit Claims Monitoring

The Commonwealth of Kentucky Personnel Cabinet, Department of Employee Insurance is requesting proposals for pharmacy benefit claims monitoring services for the Kentucky Employees' Health Plan under RFP 790-2700000038, with proposals due September 11, 2026 at 4:00 PM Eastern Time. This is a performance-based engagement with strict independence requirements that disqualify vendors with common ownership, board representation, or current service relationships with pharmacy benefit managers, third-party administrators, insurers, or entities performing drug utilization reviews.

The vendor must analyze 100% of pharmacy invoices and claims submitted by CVS Caremark or any future contracted pharmacy benefit manager, validate claim accuracy against contractual terms and plan designs in near real-time without statistical sampling, identify billing errors, and submit quarterly reports to the Personnel Cabinet and Legislative Research Commission. KEHP serves approximately 272,000 covered lives and processes over 4.5 million pharmacy claims annually. The vendor must hold a minimum of five years of direct experience in pharmacy benefit claims analysis and demonstrate analytical capability with sufficient staffing including a designated Account Manager. HIPAA compliance with a signed Business Associate Agreement is mandatory, and the vendor must maintain Commercial General Liability Insurance of at least $1 million per occurrence and $2 million aggregate, plus Professional Liability Insurance of $1 million per claim.

Compensation is performance-based at no more than 30% of documented savings identified by the vendor and verified by the Personnel Cabinet; no additional charges are permitted for travel, consulting, legal, or accounting services. The initial contract term runs October 1, 2026 through June 30, 2028, with the Commonwealth reserving renewal rights for up to two additional two-year periods subject to approval by the Finance and Administration Cabinet Secretary and the Legislative Research Commission Government Contract Review Committee.

Evaluation weights the technical proposal (vendor and staffing information, capabilities, reporting, and compliance/implementation planning) at 2,500 points, cost proposal at 500 points, and optional oral demonstrations at 500 points. Personnel Cabinet decisions regarding savings identification and fee eligibility are final and non-negotiable. All proposals must be submitted electronically through the Kentucky Vendor Self Service System and remain valid for a minimum of six months.