Summary
Provide comprehensive pharmacy benefit administration services for Inland Empire Health Plan (IEHP) across its Covered California, Medi-Cal, and Medicare Dually Eligible Special Needs Plan (D-SNP) lines of business, in full compliance with all applicable federal and California laws and regulatory requirements, including those of CMS, DHCS, and DMHC. Services shall include management of a compliant and adequate retail, mail, and specialty pharmacy network throughout IEHP’s service area; formulary development, coverage determinations, clinical programs (e.g., opioid safety, Stars); and ongoing clinical management aligned with NCQA accreditation standards and regulatory requirements such as provider and multilingual member communications; and real-time claims adjudication, eligibility integration, accurate claims processing, and coordination of benefits, including appropriate handling of vaccines and pharmacy-medical benefit crossover claims.