PHARMACY BENEFITS MANAGEMENT

The West Virginia Public Employees Insurance Agency (PEIA) is conducting a Request for Proposal (RFP) for comprehensive Pharmacy Benefit Management (PBM) services, targeting prescription drug benefits for state employees, actively employed members, non-Medicare and Medicare retirees, and their dependents. The solicitation (ARFP 0225 PEI2500000002) seeks a PBM to provide end-to-end services including claims processing, pharmacy network management, rebate administration, formulary development, clinical support, drug utilization review, and detailed reporting. Key objectives include managing prescription drug costs, with a particular focus on specialty and diabetes medications, and implementing pass-through, all-inclusive administrative services pricing. The RFP requires vendors to submit comprehensive technical and cost proposals, with specific requirements for pricing guarantees, rebate transparency, and performance metrics. Critical dates include a bidders' conference on June 3, 2025, proposal submissions due by July 11, 2025 at 4:00 PM, finalist interviews scheduled for the week of September 8, 2025, and expected PBM award notification by October 1, 2025. Evaluation criteria will likely emphasize lowest net cost, trend management, clinical program capabilities, and comprehensive specialty drug management strategies.

The procurement appears open to all qualified PBM vendors without specific set-aside designations for disadvantaged enterprises. The current incumbent is Express Scripts, serving approximately 146,337 commercial members and 8,795 non-Medicare retirees, with 99% of prescriptions obtained at retail and 1% via mail-order. The contract is structured for a three-year term effective July 1, 2026, with potential renewals, and requires vendors to be domiciled in the United States with data centers exclusively located in the 48 contiguous states. While specific award values are not explicitly stated, the RFP indicates a complex pricing model involving per-member-per-month (PMPM) administrative fees, manufacturer rebate pass-throughs, and specific reimbursement rates for pharmacies (e.g., NADAC + $10.49 for West Virginia-domiciled pharmacies). Additional financial requirements include a litigation bond of 5% of annual administrative fees and comprehensive insurance coverage. The solicitation emphasizes the need for flexibility in managing market dynamics, particularly around specialty drugs which currently consume over 40% of total drug expenditure.