Overview

The PBM Industry is rapidly changing. While your choices in the past were few, today, an extensive array of possibilities is available to lower your drug costs and improve your drug benefits, if you obtain knowledgeable consulting and legal advice.

Pharmacy Benefit Consultants can assist you in dramatically reducing your drug benefit costs, while simultaneously improving your drug benefit coverage, including by ensuring your beneficiaries use drugs more wisely:

  • Conduct A PBM RFP, But Do It Differently! When other consulting firms conduct PBM RFPs, the firms largely – or entirely – ignore the one matter that actually controls a Plan’s benefits and costs: The PBM contract. We don’t. We rely on our unique legal expertise to conduct contract-focused RFPs. We draft an entirely different form of contract before the RFP begins, “bid out” the contract, and then use the RFP’s leverage to extract the contract terms that every client needs to control and decrease its costs. Our expert clinical team also performs a detailed analysis during our RFPs of each PBM contestant’s proposed Formulary and Prior Authorization/ Step Therapy / and Quantity Limit Programs to determine the extent that each PBM contestant may be trying to obtain greater “rebates” by driving your plan beneficiaries to use higher-cost brand drugs. Thus, when our clients conclude their RFPs, our clients are presented with a PBM contract to execute that has already been fully-negotiated during the RFP, as well as with already-customized Formularies and Programs to implement that will encourage lower-cost drug utilization.
  • Obtain A Detailed Analysis of the Weaknesses of Your Current PBM Contract. Scores of our consulting firm clients have also relied on our consulting firm to review and analyze their PBM contracts. For a few thousand dollars, we provide our clients with an in-depth understanding of the weaknesses and “loopholes” in their existing PBM contract. And we make explicit recommendations for changes. As a result, we position our clients to ensure that their next PBM contract will be entirely different, based on contract terms that will ensure lower costs.
  • Instead of Conducting An Expensive & Time-Consuming Audit, Get A Claims Data “X-Ray” To Obtain A Quick And Inexpensive Understanding Of Your Costs and How To Decrease Them. Far too many entities spend large sums of money and immense amounts of time auditing their PBMs, but rarely obtain any benefits from doing so. Why? Because the entities’ PBM contracts are stuffed with “loopholes” that enable PBMs to escape reimbursement. Accordingly, our firm often recommends that clients pursue a quicker and far less expensive claims data “X-Ray”. Our firm’s claims data X-Ray assesses how much a client can save by taking certain actions to decrease its costs. Our X-Ray assesses aggregate costs and possible savings, as well as costs and savings by channel (retail, retail 90, mail and specialty). We also analyze costs by certain therapeutic categories (for example, cholesterol drugs, diabetes drugs, hep C drugs, RA drugs), identify the Plan’s “drug mix” in each category, and then calculate precisely how much our clients can save by excluding coverage for certain drugs, or increasing generic use and decreasing brand use in each category. We also compare costs across pharmacies and thus enable clients to determine how much can be saved  if certain pharmacies are excluded from their retail pharmacy networks, or other pharmacies are “preferred”. Our firm’s claims data X-Rays also focus on “disruption” – enabling our clients to determine how many plan beneficiaries will be impacted by each action they might take, and which actions will best minimize disruption.
  • Ongoing Assistance. The PBM contracts that our firm puts in place for our clients provide our clients with extensive claims data with each Invoice, as well as the ability to customize their Formularies and Programs (such as their Prior Authorization, Step Therapy and Quantity Limit Programs). As a result, our clients are not “stuck” in a static position for the 3 years of their PBM contracts, dependent on their PBMs to act in their interests and unable to respond to marketplace changes. Instead, our clients can continuously control and decrease their costs. Many choose to rely on our firm to help them do so. Accordingly, we regularly review claims data, make continuous recommendations for Formulary and Program customization, and assist our clients in responding to continually changing drug prices, as well new drugs that enter the marketplace. Our PBM contracts also provide our clients with the right to renegotiate our drug-by-drug Specialty Drug Guarantees quarterly, and all other pricing terms and guarantees annually (including Administrative Fees, all retail and mail guarantees, and all rebate guarantees), which we help them do.

Call Us To Discuss Our Cutting-Edge Strategies To Decrease Your Drug Coverage Costs, and Improve Your Drug Coverage Benefits.

Contact Pharmacy Benefit Consultants for further information.