Pharmacy Benefit Services (PBS)

The South Carolina Department of Health and Human Services is requesting proposals for Pharmacy Benefit Services (PBS) covering claims adjudication, benefit plan management, prior authorization, drug utilization review, and drug rebate management, with proposals due September 1, 2026.

The scope encompasses Single State Directed Pharmacy Benefit administration, physician-administered drugs, and clinical programs serving Medicaid beneficiaries. The contractor must manage real-time claims processing meeting NCPDP compliance standards, prospective and retrospective drug utilization review, Preferred Drug List management, prior authorization decisions with 24-hour response times, drug rebates with 100 percent accuracy standards, and financial modeling. Licensed pharmacists must be available 8 a.m. to 6 p.m. Eastern time for clinical consultation, participation in weekly and bi-weekly clinical meetings, and utilization management appeals support. The contractor is responsible for maintaining comprehensive documentation, processing claims within federal standards, managing multiple pricing algorithms at the NDC level, administering 340B program participation, managing third-party liability, and providing detailed reporting on program performance, savings, and compliance metrics across multiple reporting frequencies (weekly through yearly).

All proposals containing Artificial Intelligence or Machine Learning components must comply with NIST AI Risk Management Framework standards, disclose all AI/ML uses and workflows, document human review and override capabilities for final decisions, prohibit use of SCDHHS PHI or PII for model training without written authorization, and implement bias and fairness assessments before deployment and on a recurring basis. The contract structure includes Implementation, Operations, and Turnover phases, with a base term of three years (Years 1–3) and four optional renewal years (Years 4–7), plus a modification pool not to exceed five million dollars for agency-approved system modifications. Bidders must submit a completed Rate Card with hourly labor rates to support subsequent change orders. All responding contractors must provide minimum three references documenting previous experience with similar claims management and CMS certification projects, including contract terms, customer contacts, scope descriptions, project outcomes, team size, and contract value. Contractor solutions must also be HIPAA Business Associate compliant and subject to mandatory organizational conflict-of-interest disclosure. Oral presentations and demonstrations are part of the evaluation process.