Pharmacy Benefit Management Services

STATE OF DELAWARE
Department of Human Resources
State of Delaware
Department of Human Resources
Statewide Benefits Office
STATE EMPLOYEE BENEFITS COMMITTEE
Request for Proposal for Professional Services
for the State of Delaware's
Pharmacy Benefit Management Services
DHR25006A-PBM (REBID)
RFP Release Date
Wednesday, March 25, 2026
Intent to Submit Proposal Deadline -
Wednesday, April 1, 2026, 11:00 a.m. ET (Local Time)
Mandatory Pre-Proposal Meeting (Virtual) -
Thursday, April 2, 2026, 11:00 a.m. ET (Local Time)
Proposals Due -
Monday, April 27, 2026, by 1:00 p.m. ET (Local Time)
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STATE OF DELAWARE
Department of Human Resources
Contents:
I. Overview
II. Scope of Services
III. Required Information
IV. Professional Services RFP Administrative Information
V. Contract Terms and Conditions
VI. RFP Miscellaneous Information
VII. Attachments
Appendix A - MINIMUM MANDATORY SUBMISSION REQUIREMENTS
Appendix B - PROFESSIONAL SERVICES AGREEMENT TEMPLATE1
** Ctrl+Click on the headings above will take you directly to the section.
I. Overview
The State of Delaware, Department of Human Resources ("DHR"), on behalf of the State Employee
Benefits Committee ("SEBC"), seeks professional services to enter for the purpose of administering
its Pharmacy Benefit Management Services. This request for proposals ("RFP") is issued pursuant to
29 Del. C. 6981 and 6982.
For complete information about the State of Delaware's benefit programs, please go to
https://de.gov/statewidebenefits.
The proposed schedule of events subject to the RFP is outlined below. However, these dates and
milestones are not absolute and may change due to unplanned events during the bid proposal and
award process:
Event Target (Local ET Time)
RFP Released Wednesday, March 25, 2026
Intent to Submit Proposal Deadline Wednesday, April 1, 2026, 11:00 a.m.
Mandatory Pre-Proposal Meeting Thursday, April 2, 2026, 11:00 a.m.
(Conference Call)
Questions due to SBO from Monday, April 6, 2026, 9:00 a.m.
Confirmed Vendors
1 Please note that this RFP contains modifications to the Professional Services Agreement template at Section V, which the State expects to
be incorporated into the resulting contract.
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STATE OF DELAWARE
Department of Human Resources
Event Target (Local ET Time)
Responses to Questions to Confirmed By Friday, April 17, 2026
Vendors
Deadline for Receipt of Proposals Monday, April 27, 2026, by 1:00 p.m.
Monday, June 15, 2026
Notification of Finalists -
Invitation to Interview
Finalist Interviews August 31, 2026, and September 1, 2026
Recommendation of Finalist(s) to SEBC October 2026
Each proposal must be accompanied by a transmittal letter which briefly summarizes the proposing
firm's interest in providing the required professional services. The transmittal letter must also clearly
state and justify any exceptions to the requirements of the RFP which the applicant may have taken in
presenting the proposal. (Applicant exceptions must also be recorded on Attachment 3).
Furthermore, the transmittal letter must attest to the fact, at a minimum, that the vendor shall not store
or transfer non-public State of Delaware data outside of the United States. For technology related
solicitations, vendors may refer to the Delaware Department of Technology and Information identified
terms and conditions included in this solicitation.
The State of Delaware reserves the right to deny any and all exceptions taken to the RFP requirements.
MANDATORY PRE-PROPOSAL MEETING
A mandatory pre-proposal meeting has been scheduled for Thursday, April 2, 2026, at 11:00
a.m. ET (local time) via Microsoft Teams.
Proposals will not be accepted if the interested vendor does not participate in the mandatory pre-
proposal meeting. Topics will include general information and administrative requirements for
proposal preparation. The primary contact for the RFP should attend along with anyone who is
primarily responsible for entering responses in ProposalTech as described in Section IV.B. Only one
person acting as the representative from the interested vendor is required to attend, but anyone on the
team is welcome to participate. A roll call will be taken to confirm attendance.
Meeting minutes may be taken. If new or additional information is provided, an addendum may be
released to address information provided during the mandatory pre-proposal meeting. Questions
regarding other topics will not be entertained and must be submitted as part of the Questions and
Answers process as described in Section IV.B.
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II. Scope of Services
A. Background and History
1. Overview of the SEBC
The SEBC was established by the State Employee Benefits Consolidation Act, 29 Del. C. ch 96.
The SEBC has control and management of all employee benefits. The SEBC selects all carriers or
third-party administrators necessary to provide coverage to State employees and non-Medicare
and Medicare retirees, enters into contracts for the purpose of general administration of employee
benefits, determines if/whether contracts are to be fully insured or self-insured, and adopts rules
and regulations for the general administration of the employee benefit coverage.
Membership of the SEBC is determined by 29 Del. C. 9602. The Statewide Benefits Office
("SBO") is a division within DHR. SBO functions as the administrative arm of the SEBC and,
with the exception of pension and deferred compensation benefits, is responsible for the
administration of all statewide benefit programs. These programs include, but are not limited to,
health with wellness and disease management programs, prescription drug, dental, vision,
disability, life, flexible spending account program, pre-tax commuter program, employee
assistance program, third-party network of surgeons of excellence and supplemental critical illness
and accident benefits. Visit https://dhr.delaware.gov/benefits/ for information about the programs.
Some programs are not offered to all benefits-eligible plan participants; specific details on the
programs relevant to this RFP are described in the next section further below.
Benefit eligible plan participants include the State's active employees (State agency, school
district, charter school, Delaware State University, and Delaware Technical Community College
employees) and their dependents; non-Medicare and Medicare retired employees and their
dependents; employees of non-State groups (i.e., towns and fire companies these groups are also
referred to as "participating groups" or "non-payroll group" employees) and their dependents; and
COBRA participants. By statute, employee unions cannot negotiate for benefits. Plan participants
are primarily located within the State of Delaware, although a small number of participants reside
in other states and countries.
2. Program Information
Currently, Highmark Delaware and Aetna administer the medical portion of the GHIP and CVS
Caremark administers prescription drug services. The State will be marketing the medical plan
(excluding pharmacy) during the summer of calendar year 2026. The State reserves the right to
change its medical Third-Party Administrators (TPAs) and/or Pharmacy Benefit Management
(PBM) at any point during the term of its contract.
The Delaware General Assembly has introduced numerous bills related to PBMs and prescription
drugs over the last decade, many of which have been signed into law. Attachment 23 contains a
current listing of relevant bills, including those that have been introduced during the 153rd General
Assembly (January 2025 - June 2026). Bidders shall comply with all federal, state, and local laws,
regulations, and guidance impacting pharmacy benefit activities. Further details on these bills can
be located at https://legis.delaware.gov/.
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STATE OF DELAWARE
Department of Human Resources
Current
Membership
Commercial1 96,167
EGWP2 28,167
Grand Total 124,334
B. Scope of Services
The SEBC desires to contract with an independent organization(s) specializing in providing
commercial (non-Medicare) and Employer Group Waiver Plan (EGWP) Medicare Pharmacy
Benefit Management Services for large municipalities and State governments with similar
experience in depth and scope of services in the private sector. The organization(s) must have prior
experience directly related to the services requested in this RFP and must be able to clearly
demonstrate their ability to meet the general evaluation requirements in Section III.
***IMPORTANT*** The SEBC seeks a pharmacy benefit management partner for prescription
drug benefit services effective July 1, 2027, with minimal disruption in member experience and
clinical oversight. The State of Delaware is not interested in contracting for any arrangement that
would force the State to give up any decision-making control over the administrative or clinical
management of its pharmacy benefits program. Today, the State has decision-making authority to
determine which programs and services are provided to its population by the incumbent PBM.
The State also has the ability to make exceptions to plan coverage determinations with the
exception of the standard Medicare Part D EGWP benefit.
A general overview of the Scope of Services is as follows:
The organization must have prior experience directly related to the services requested in this RFP and
be able to demonstrate clearly its ability to:
* Offer state-of-the-art prescription drug benefit management services;
* Provide clinically and financially appropriate management programs;
* Provide transparency in contracting terms with drug manufacturers, drug distributors, including
wholesalers, Pharmacy Services Administrative Organizations, and pharmacy networks for both
traditional and specialty drugs;
* Provide competitive financial terms;
1 Commercial (Non-Medicare lives)
2 EGWP (Employer Group Waiver Plan) is a group Medicare Part D prescription drug plan offered to retirees.
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STATE OF DELAWARE
Department of Human Resources
* Provide excellent customer service to participants;
* Provide excellent account management services to the State, including timely reporting;
* Meet or exceed performance guarantees; and
* Be responsive to requests of the SEBC.
The selected organization is required to provide the following Scope of Services, at a minimum3:
a. Prescription claim adjudication.
b. Participant enrollment maintenance including the capability to accept and process enrollment files
from the medical Third-Party Administrators' (TPAs) (currently Highmark and Aetna) designated
format.
c. Comprehensive management of the Medicare Part D EGWP including the ability to maintain
benefits for Medicare retirees who are awaiting their EGWP enrollment approval by the Centers
for Medicare and Medicaid Services (CMS).
d. Secure transmission of enrollment and claims data to the Delaware Health Information Network
(DHIN) and the State of Delaware's data warehouse vendor as well as detailed rebate data to the
data warehouse vendor.
e. Patient and provider education.
f. Network pharmacy management, including a 90-day retail network.
g. Formulary management and rebate administration.
h. Systematic prospective, concurrent, and retrospective drug utilization review.
i. Clinical management programs including prior authorization and appeals processing.
j. Fraud, waste, and abuse detection and prevention programs.
k. Mail order and specialty pharmacy services.
l. Dedicated, knowledgeable, and accessible member support services.
m. Secure and multifunctional member website that allows convenient access to enrollment and plan
information.
n. Meaningful and timely management reporting.
o. Integration with the State's medical and wellness programs and providers for
utilization/care/disease management, medical health savings account (HSA), as applicable.
3 This is a general list of services. Details are set forth in the minimum qualifications and questionnaire sections.
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STATE OF DELAWARE
Department of Human Resources
p. Dedicated, expert, and accessible account management staff.
q. Support for all program related member communications including open enrollment, direct
mailings, and other types of media.
r. Superior program implementation support.
s. Provide rebate reporting by individual drug and drug class can be shared on all drugs and drug
classes.
t. Actively and proactively engage in cost savings conversations and programs to lower prescription
pricing.
For a more detailed Scope of Services, please refer to the Response to Scope of Services Questionnaire
("Questionnaire") contained at Attachment 22.
III. Required Information
The following information shall be provided in each proposal in the order listed below. Failure to
respond to any request for information within this proposal may result in rejection of the proposal at
the sole discretion of the State.
A. Minimum Requirements
1. Clarify whether you are bidding on commercial or EGWP or both.
2. Confirm your ability to process prescription claims beginning on July 1, 2027, for the non-
Medicare population and beginning on January 1, 2028, for the Medicare Part D EGWP
population.
3. Confirm your agreement to accept the data elements in the file feeds from the GHIP's medical
TPAs (currently Highmark and Aetna) along with claims data to be sent to DHIN and the
State's data warehouse vendor - see Attachment 32 for all file layouts. Changes, either of a
data type or addition of a data type, may not be accepted. Be sure to detail any potential
expectations for changes.
4. Confirm that your proposed PBM services will allow the State to retain decision-making
authority over the pharmacy benefits provided under the State Group Health Plan; specifically,
the State will retain the authority to determine which programs and services are provided to its
population and make exceptions to plan coverage determinations.
5. Confirm that the State will maintain the ability to carve-out specialty dispensing and
management to an outside best practice entity of its choice should the State decide to take an
alternative specialty approach.
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STATE OF DELAWARE
Department of Human Resources
6. Confirm your organization will provide a pricing offer that will be separate for Commercial
and EGWP populations if bidding on both plan options (i.e., the Commercial offer will not
assume the EGWP population is implemented, and vice versa).
7. Confirm your organization has reviewed the applicable legislation requirements in Attachment
23 and confirm your organization will comply with all applicable current state and federal
pharmacy laws and regulations effective on or before the effective date of the contract(s) to be
awarded from this RFP.
8. Confirm your organization will comply with all state and federal Pharmacy laws, regulations,
and guidance, including all CMS-mandated requirements if bidding on EGWP, including any
such laws, regulations, or guidance that become effective after the contract effective date and
during the term of the contract(s).
9. For the purposes of data sharing, including eligibility and claims information, confirm that you
will agree to enter third party agreements with the GHIP's medical TPAs (currently Highmark
and Aetna), DHIN, and the GHIP's data warehouse vendor (currently Merative), and future
vendors, as applicable.
10. Confirm your organization is a registered PBM in Delaware or will become registered by June
1, 2026. If you are a registered PBM in the State of Delaware, please provide your nine-digit
PBM Registration Number (XX_XXXXXXX).
11. Confirm your organization has at minimum, 3 consecutive years of experience providing the
Scope of Services requested in this RFP (e.g., commercial and EGWP if applicable).
12. Confirm your organization complies with all provisions of Delaware law regarding licensing
of a PBM as detailed in Title 18 of Delaware Code and is up to date with all relevant registration
and renewal fees.
13. Confirm your organization has experience managing pharmacy benefit services for at least 3
clients with similar scopes of services as requested in this RFP, which cannot include health
plans. If bidding on both Commercial and EGWP, this should include 3 clients with similar
scopes of services for each line of business.
14. Confirm your organization will assign an Account Executive and Account Manager if awarded
the State business, each with a minimum of 5 years' experience in the healthcare industry and
having worked with clients of similar size and complexity. In addition, confirm that the
proposed Account Executive and Account Manager will have worked for your organization a
minimum of 3 years in their current role. If these roles fall under a different title in your
organization, please describe the position(s) that would be responsible for supporting this
work.
15. Confirm if your organization will agree to pass through 100% of all rebates received from
pharmaceutical manufacturers as a result of the State utilization, including manufacturer
administration fees. The SEBC's definition of "Rebate" means a discount or other price
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STATE OF DELAWARE
Department of Human Resources
concession, or a payment that is:(i) based on utilization of a prescription drug; and (ii) that is
paid by a manufacturer or third party, directly or indirectly, to a pharmacy benefits manager,
pharmacy services administrative organization, pharmacy, or Group Purchasing Organization
(GPO), rebate aggregator, vendor, TPA or any affiliate of the PBM on or after a claim has been
processed and paid. "Rebate" includes without limitation incentives, disbursements, and
reasonable estimates of a volume-based discount.
If your organization uses a different definition of the term "Rebate," please provide that
definition for the State's review and consideration. If your proposed model does not include
rebates, please include in your proposal(s) your organization's policies regarding the payments
received as detailed above.
16. The State is interested in evaluating alternative pricing proposals, including acquisition
cost/cost plus pricing proposals. Confirm if your organization will provide an alternative
pricing proposal, such as an acquisition cost/cost plus pricing proposal, that includes the
elimination of spread pricing as defined as any difference between the amount paid by the State
and the amount reimbursed to the pharmacy for all prescription claims. An acquisition cost
pricing proposal should include those medications dispensed at Mail Order and Specialty and
the full pass-through of all pricing components, with minimum guarantees. You are strongly
encouraged to submit an alternative pricing proposal, though failure to submit an alternative
pricing proposal will not result in disqualification from this procurement.
17. Confirm that your organization will provide a transparent cost pricing proposal to the State. A
transparent pricing proposal should include the full pass-through of all retail and should also
include rebate components from all channels including retail, mail order, and specialty, with
minimum guarantees.
18. Confirm your organization will allow the State the right to audit all aspects of the State's
pharmacy benefit program managed by you including, but not limited to, financial terms,
claims payments, the specialty program, service agreements, administration, guarantees,
ability to view contracts and all transparent and pass-through components including rebates
and acquisition cost pricing, as applicable.
19. Confirm your organization's understanding that the State may audit all components of the plan
at any time after the effective date of the contract including up to 3 years following the
termination of the pharmacy benefit management agreement at no cost to the State. The review
of all aspects of the pharmacy benefit program may include, but will not be limited to: paid
claims, the claim processing system, rebate agreements, performance guarantees, retail
network, acquisition pricing, Medicare Part D reconciliations, transparency, pricing
benchmarks (e.g., AWP source), onsite assessments and customer service call monitoring.
20. Confirm your organization will provide reporting on the acquisition cost of all claims
dispensed under the plan, even if the State does not implement an acquisition cost arrangement.
21. Confirm your organization's understanding that rebate guarantee modifications of the contract,
if applicable, will not be allowed unless the State changes to the formulary result in a 10% or
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STATE OF DELAWARE
Department of Human Resources
greater loss in total rebates to the GHIP. Any changes to the rebate guarantee, based on the
State's changes to the formulary, will be based on the actual reductions in rebate revenues
related to that decision and will be fully supported by documentation made available to the
State and its consultants by the PBM on a prospective basis only.
22. Confirm your organization will provide NDC-9 rebate reporting in accordance with the
definition of rebates as agreed upon with the State if awarded the contract(s).
23. Confirm your organization will provide responses to the RFP scope of work and clearly
identify capabilities as presented in the General Evaluation Requirements outlined in the State's
public notice.
24. Confirm your organization will complete all appropriate attachments and forms as identified
within the RFP.
25. Confirm your organization will provide proof of insurance and amount of insurance prior to
the start of the contract period and that coverage will be no less than as identified in the bid
solicitation, Section V, Item G, Subsection 7 (insurance) and Attachment 21, Cyber
Responsibilities, Liability and Insurance. The insurance amounts outlined in this RFP are final
and non-negotiable.
B. General Evaluation Requirements
1. Responsiveness
2. Financial Terms
3. Network and Formulary
4. Administrative Services
5. Audit Rights, Transparency/Net Cost, and Flexibility
6. Ability and Capacity to Provide Requested Services
IV. Professional Services RFP Administrative Information
A. RFP Issuance
1. Public Notice
Public notice has been provided in accordance with 29 Del. C. 6981.
2. Obtaining Copies of the RFP
This RFP is available in electronic form through the State of Delaware Procurement website
at https://bids.delaware.gov/. Paper copies of this RFP will not be available.
3. Assistance to Vendors with a Disability
Vendors with a disability may receive accommodation regarding the means of communicating
this RFP or participating in the procurement process. For more information, contact the
Designated Contact(s) no later than ten days prior to the deadline for receipt of proposals.
4. RFP Designated Contacts
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