Claims Data “X-Rays”

Many PBM Clients spend tens of thousands of dollars conducting audits of their existing PBM contracts.  Unfortunately, almost all PBM/client contracts are so stuffed with “loopholes” and ambiguous language that clients almost never collect reimbursements from their audits. Moreover, even if clients do extract PBM compensation at the end of audits, given the “loose” contract terms that exist in most contracts, PBMs typically increase their costs after audits have ended and “take back” whatever payments may actually get made.

Our firm has developed a far less expensive and faster means for you to assess your current costs, determine the competitiveness of those costs, and project your likely savings if you change your existing PBM contract.

We take an “X-Ray” of your recent claims data, by
(i) Re-categorizing “brand drugs,” “generic drugs” and “specialty drugs” (since we know that many PBMs are incorrectly categorizing drugs);
(ii) Determining your actual costs for each category of drugs;
(iii) Drilling down into the detail of commonly used drugs to determine your actual costs for those drugs; and
(iv) Thereafter projecting how much you will save if you eliminate the “loopholes” in your existing PBM contract and implement an airtight contract with pricing terms and guarantees that are currently available in the marketplace.

By conducting a quick and inexpensive “X-Ray” of your claims data, you can turn to the tasks that will actually save you money: Conducting a contract-based RFP, and Renegotiating your PBM/client contract.

After you have a new “airtight” PBM contract in place, you’ll be able to conduct audits, determine your PBM’s contract compliance, and know you will be fully compensated if your PBM has failed to satisfy your contract terms.

Accordingly, if you want or need to know whether your PBM is charging you unfairly, contact our firm to conduct an inexpensive and quick “X-Ray” of your claims. You’ll learn exactly what you need to know in a matter of days – and position yourself to change your prescription coverage costs immediately.