Pharmacy Benefit Manager Auditor

2026-11-03

Procurement Overview and Goals . Minnesota Management and Budget (“ MMB ” or “ State ”) is soliciting proposals from which to select a vendor to provide auditing services of the State ’ s pharmacy benefit manager . The State is currently in the fourth year of its PBM contract with CVS Caremark , with one ( 1 ) year remaining for the potential extension through December 31 , 2027 . The goal of these services is to ensure the State ’ s pharmacy benefit manager ( PBM ) is accurately administering the State Employee Group Insurance Program ’ s ( SEGIP ) and the Public Employees Insurance Program ’ s ( PEIP ) pharmacy benefit in accordance with the contract terms agreed upon between the State and its contracted PBM vendor . The vendor selected from this RFP will perform , at a minimum , traditional audit services , manufacturer - derived revenue ( rebate ) audits , analyses , and reporting to ensure all financial and pricing terms in the State ’ s PBM contract are correctly applied , appropriate and effective controls are in place , and the State has appropriate cost - containment measures included in its PBM contract . Responders are encouraged to suggest additional services that may support the State ’ s procurement goals , such as but not limited to , ongoing real - time claims monitoring services , market checks , or procurement assistance services . The selected vendor may be asked to assist with ancillary duties related to this RFP as agreed upon by the State and selected vendor . Vendor Responsibilities . Specifically , at a minimum , the State is seeking the following information based on six ( 6 ) types of audits ( a - Plan design benefits , b - Financial and pricing , c - Eligibility , d - Manufacturer - derived revenue [ rebate ], e - Performance guarantee , f - Fraud , waste and abuse [ FWA ] audit ): Audits & Analysis Benefit Design : Whether the PBM is administering SEGIP ’ s and PEIP ’ s benefit designs in accordance with the State ’ s PBM contract ; Financial and Pricing : Whether the State ’ s PBM vendor is accurately applying the financial and pricing terms per the terms of the State ’ s PBM contract . This analysis will include : An assessment of dispensing fees , discounts , and contract provisions about reimbursement for drug costs ; Issues such as whether brand and generic drugs are being classified appropriately ; An analysis of claims and costs for compound drugs , drugs covered by the 340B Drug Pricing Program , specialty pharmaceuticals , mail - order drugs , and 90 - day retail programs ; Utilization Management : An assessment of the PBM ’ s effectiveness at reducing inappropriate utilization through its initiatives to detect and reduce fraud , waste , and abuse ; Pass - throughs : An assessment of the PBM ’ s performance in calculating and passing through all sources of manufacturer - derived revenue ( including but not limited to rebates and group purchasing organization fees ) to SEGIP and PEIP in accordance with the terms of the State ’ s PBM contract . Evaluate the PBM ’ s activities and diligence in pursuing collection of manufacturer - derived revenue . Evaluate whether any manufacturer - derived revenue is not passed through to the State due to various factors , such as the utilization of affiliated entities . Assess the financial impact to the State of formulary exceptions and products that are not considered a Covered Product . The Responder may propose conducting a preliminary “ desktop ” audit with optional follow - up onsite at the PBM ’ s offices as needed or may propose a platform - based audit .

Minnesota

2026-04-29