Pharmacy Drug Benefits

The Texas Health and Human Services Commission (HHSC) is requesting proposals for Pharmacy Benefits Manager services to administer pharmaceutical benefits for the Texas HIV Medications Program under RFP HHS0017240, with proposals due November 19, 2026.

The scope encompasses pharmacy benefits administration for three programs — State Pharmacy Assistance Program (SPAP), Texas Insurance Assistance Program (TIAP), and Texas Insurance Assistance Program-PLUS (TIAP-PLUS) — providing cost-sharing assistance by coordinating payment of deductibles, copayments, coinsurance, and insurance premiums. The contractor must maintain a statewide pharmacy network with mail order and rural coverage, operate a bilingual help desk Monday–Friday 8:00 a.m. to 7:00 p.m. Central Time, provide electronic claims and enrollment data access to DSHS, and ensure Medicare Part D coordination of benefits compliance. Key deliverables include operational and transition plans due within specified timeframes, monthly claims-level and premium payment reports (first Friday of each month), weekly adjudication-limitations reports, quarterly 340B rebate and compliance reports, and annual benefits reports. The contractor must achieve Texas Risk and Authorization Management Program (TX-RAMP) Level 2 Certification if offering a Software-as-a-Service portal (provisional certification permitted initially). Compliance with HIPAA, NCPDP standards, CMS Coordination of Benefits guidelines (January 2026), and Texas Health and Safety Code Chapters 81 and 85 is mandatory.

The contract term is 12 months initial plus four optional 12-month extension periods (60 months total). Compensation is fee-for-service: per-claim adjudication fees, premium payment and medication-cost reimbursement, premium payment fees, and service-related fees invoiced bi-weekly, with historical utilization estimated at 8,455 claims per month and 334 participants per month (evaluation purposes only; no guaranteed volumes). The contractor must maintain Commercial General Liability ($2 million per occurrence / $4 million aggregate), Cyber/Privacy Liability ($5 million), Professional Liability ($5 million), Technology Professional Liability Errors and Omissions ($5 million), and Umbrella Liability ($10 million). Respondents must complete all HHS Solicitation Affirmations (Version 2.10), Data Use Agreement (Version 8.5), Security and Privacy Inquiry, cost proposal in Excel format, and insurance documentation. Responses may be submitted through the optional HHS Online Bid Room (requiring IAMOnline registration) or by other solicitation-specified methods.