Pharmacy Benefit Manager
When it comes to drug costs,
what you don’t know can hurt.
Drugs costs have skyrocketed in recent years. Our Pharmacy Benefit Manager (PBM) Services team levels the playing field by providing transparency and monitoring performance. Whether you need a retrospective audit of contract performance, a near real-time monitoring solution, or a deeper look into a PBM’s regulatory compliance, our team has the answer.
Our services are designed to help clients shed a new light on the complexities of the PBM industry — providing data and insights that maximize accountability, transform ambiguity and manage drug spend.
DOLLARS CAPTURED
We’ve helped clients capture more than $1 billion in litigation and financial recoupment.
Our Pharmacy Benefit
Manager Solutions:
Retrospective Audit
Our retrospective analyses and audits provide a deep dive into the internal claims adjudication process, allowing you to review PBM performance, identify problem areas, and correct underperformance. The insights you gain can be used for litigation, financial recoupment, or guiding future contract negotiations with PBMs. Our audits cover PBM claims data, contractual terms and plan design, and enable you to identify claim adjudication errors such as:
- Contract Performance Guarantees (based on both pricing and dispensing fees)
- Usual and Customary Pricing
- Lesser of Logic Pricing
- Early Refills
- DAW 9
- Rebate Guarantees
- Spread Pricing
- Administration Charges
- MAC Pricing
- Pricing Methodology Comparison
- Specialty Pricing
- 340B Pricing
Near Real-Time Monitoring
By using advanced data solutions, our team can continuously collect and analyze PBM performance on an invoice-by-invoice basis, and deliver actionable evaluations before payment is due. As a result, states can correct potential billing errors before taxpayer dollars and employee contributions need to be recovered.
In addition, our near real-time monitoring of PBM performance provides immediate transparency. This enables you to spot patterns of behavior in PBM business practices as they’re happening, without the delays of waiting for a year-end audit. This gives state agencies the opportunity to identify new questionable practices and stop them in their tracks, so that they can protect health plan members and client resources going forward.
Regulatory Compliance
- Reviewing internal PBM policies and procedures to determining alignment with laws, statutes, and regulations.
- Identifying gaps between PBM policies and procedures and applicable laws.
- Review data to determine whether gaps are manifesting as exceptions or problems for patients and pharmacies.
Procurement
We help state agencies improve their procurement processes and practices by collaborating with them in key areas such as:
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Vendor Selection
Develop requests for proposals (RFPs), evaluate proposals, and select finalists.
Contract Writing
Write, negotiate, analyze, and audit their contracts with PBMs.
Cost Management
Identify ways to reduce costs without sacrificing quality of care.
Clinical Management
Our clinical pharmacists work with plan members and medical providers to ensure that medications are appropriate and that they are being used safely and effectively.
Audit Management
Conduct audits of PBM rebates and other financial benefits.
Plan Design
Design future PBM contracts to meet specific needs.
Market Analysis
Conduct annual market analysis to determine if a PBM is providing best in class service and pricing.
