Specifications include, but are not limited to: Pharmacy Benefits Manager on behalf of the Department of Human Services. 1.1 Medicaid Fee For Service (FFS): The awarded Vendor shall provide the following services for this scope. 1.1.1 Claims Processing and Operational Support: The PBM must ensure claims processing policies and procedures are compliant with all applicable territory and federal laws, regulations, rules, and policies. Claims adjudication is the responsibility of the PBM. A. The Vendor must describe its approach for handling pharmacy payments. This will involve submitting files to USVI Medicaid for payment purposes. B. In adjudicating claims the PBM shall perform several prescribed functions including applying drug utilization review edits, ensuring existence of prior authorizations when required, and coordination of benefits functions. 1.1.2 Pharmacy Point-of-Sale (POS): The PBM will operate a real‐time (POS) online claim processing system with current National Council for Prescription Drug Programs (NCPDP) format and guidelines with an emphasis on drug utilization review (DUR), utilization management (UM), prior authorization, messaging, processing, and reimbursement for clinical services, and the Public Health Service Act 340B eligible drugs where applicable. The POS online system will be required to isolate 340B claims for the purpose of preventing duplicate discounts. The PBM’s POS claims processing system must be capable of adding, changing, or removing adjudication rules, edits, and customized transmission messages to accommodate required changes for its current and future pharmacy programs. The system must be capable of displaying the Preferred Drug List (PDL) status of a drug.
