Request for Proposal for Pharmacy Benefit Management and Claims Administration Program

The County of Orange is seeking a Pharmacy Benefit Management (PBM) and Claims Administration Program through a Request for Proposal (RFP) for its self-insured health plans, including Sharewell and Wellwise PPO plans for employees, non-Medicare and Medicare retirees, and their dependents. The procurement aims to select a contractor for a three-year contract with two optional one-year renewal terms, with an anticipated contract start date of January 1, 2026. The selected PBM must work closely with Blue Shield of California and Alight Solutions to coordinate eligibility, claims processing, and administrative functions, with comprehensive services including customer support, claims processing, clinical programs, and compliance with healthcare regulations. Key requirements include extensive experience with public sector clients, a broad pharmacy network in California, and the ability to manage both commercial plans and an Employer Group Waiver Plan (EGWP) for Medicare retirees. The RFP was posted on January 7, 2025, with proposals due on February 13, 2025, and planned vendor presentations scheduled for March 27, 2025. The current pharmacy program is administered through OptumRx, and the County seeks a vendor that can seamlessly integrate with existing healthcare infrastructure and meet the specific needs of their diverse health plans.

While no specific set-aside designations or restrictions on respondent types were explicitly mentioned in the documents, the RFP suggests a preference for vendors with substantial public sector experience and robust capabilities in pharmacy benefit management. The current pharmacy claims administration is managed by OptumRx in a carve-out arrangement with Blue Shield of California, indicating potential opportunities for incumbent and new vendors. The health plans covered by this RFP include multiple PPO options: Sharewell Choice, Wellwise Choice, Wellwise Medicare Retiree, Wellwise Non-Medicare Retiree, and Sharewell Retiree, each with detailed benefit structures and prescription drug coverage. While a specific budget range was not disclosed, the comprehensive nature of the contract covering multiple health plans for county employees and retirees suggests a significant potential contract value. The selected PBM will be responsible for managing prescription drug benefits across these plans, including network pharmacy services, claims processing, clinical programs, and coordination with medical plan administrators.