Auditing PBM Agreements Can Save Money

PBIRx®
Intelligent Solutions in Pharmacy Benefits
12 Wheelers Farms Road, Milford, CT 06461
(888) 797-2479

“Pharmacy” benefit costs in the US are predicted to increase from $323 Billion in 2016 to $580-$610 Billion in 2021 according to a report by QuintilesIMS Holdings, Inc.    

Pharmacy Benefit Managers love when their clients do NOT audit their pharmacy benefit agreement!   This way the creative language in their contracts is not revealed and you pay more and more each month and each year.

Auditing pharmacy claims can generate significant monetary recoveries, while at the same time providing you with the confidence that your current pharmacy benefit financial discounts and guarantees are competitive for 2017.  PBIRx can tell you what parts of your PBM contract are not competitive. PBIRx clients experience a 5%–15% recovery of total drug spend, while at the same time ensuring that the PBM contract financial terms are being adjudicated correctly.

PBIRx®, a pharmacy benefit auditing and consulting corporation with locations in Connecticut and Missouri  since 1993, has the technology, tools, years of experience and experts that can help you recover lost dollars using our AuditRx® technology.   

PBIRx has several references nationwide that will attest to not only the audit recoveries that we facilitate, but also the savings to their pharmacy benefit budget.  Pharmacy Benefit Agreements, whether direct with the PBM, through the health plan carrier (i.e. Anthem, Cigna, Aetna, etc), or through a coalition, state that auditing may be limited to a certain time period (typically the previous 12 months).  Not knowing the period of time that you can audit your pharmacy benefit claims and not reaching out to PBIRx results in a lost recovery opportunity!

Why you should have PBIRx review your Pharmacy Benefit Agreement with no fee:

• To determine if there is a potential pharmacy benefit claims  recovery
• To know if the discounts in the PBM Agreement are actually being adjudicated as stated
• To learn if the financial model (discounts, rebates, guarantees, etc.) is 2017 competitive
• To provide union negotiated pharmacy benefits at a lower cost
• To know if there are other opportunities for savings to reduce costs while maintaining current copays and plan design features in negotiated union contracts
• To be reminded of important dates that could result in lost “time value of money”, i.e. guarantee/rebate remittance, agreement renewal period, non competitive automatic renewals, etc.

PBIRx will provide a courtesy review of your PBM agreement upon request.  Please contact David Sirowich at dsirowich@pbirx.com or call 203-882-1188 to discuss your potential savings in greater detail.  You can also visit our website www.pbirx.com for more information.

PBIRx has been exclusively providing intelligent solutions to clients in the management of pharmacy benefit costs since 1993. With a staff that includes IT personnel, actuaries, financial analysts, clinical pharmacists, attorneys, HIPAA Compliance Officers and many more experts, PBIRx’s mission is to create optimal health care outcomes while minimizing overall health care costs. For more information, please visit www.pbirx.com or call (888) 797-2479.

Three Things You Must Understand In PBM Contracts

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

As the person in charge of your company’s pharmacy benefits, one thing you are surely held responsible for is understanding the contract between you and your PBM, which means understanding how the “words” in the contract change/effect the “numbers” or financial terms. However, since these can be rather complex, we know it may be difficult for some to fully grasp what the language really means. That is why as your expert pharmacy benefit consultant, we have listed three things you must know below:

Drug classifications and cost: Though generic drugs and brand name drugs are equivalent to one another in their composition and overall purpose, a major difference between the two is the price. It is important to know that PBMs state in the contracts that they often have a “proprietary algorithm”, which allows them to choose which drug they designate as generic and which as a brand drug. Similarly, you should also be aware of not only the pricing of specialty drugs, but also how they differ from Limited Distribution Specialty drugs and how the prices changes on a continuum. Have you been monitoring the discounts applied to existing and new high cost specialty drugs utilized by your plan? Probably not, and the PBMs take great advantage of that lack of monitoring.

Rebates: As there are plenty available, you must make it a point to discuss rebates with your PBM. However, at PBIRx we are fully aware that this is one topic PBMs often fail to comply with, which is why we highly recommend taking advantage of our auditing service AuditRx®. By allowing us to analyze your plan, we can discover any gray areas and generate recoveries for you.

New approvals: What procedures does your PBM follow when new drugs hit the market or when the PBM excludes drugs from the  formulary? Many times the drugs are similar to or more costly than the excluded drugs; however, the PBM receives significant rebates for these drugs. Do you discuss with your PBM what percentage of those rebates you are receiving for those drugs and when you will receive those rebates, especially as pharmacy costs continue to rise with little sign of slowing down? Remember that PBMs disclose that you do NOT receive the interest value of any monies they receive and hold until contractually required to remit to clients, i.e. rebate remittance.

Even after you have gone through topics like these with your PBM and have thoroughly read your pharmacy benefit contract, it would still be in your best interest to connect with a pharmacy benefit consulting firm like PBIRx. Simply put, it is our priority to ensure that all actions taken are in your favor, as opposed to the PBM’s, and PBIRx is dedicated to finding your company any and all cost-saving opportunities that are available to save money in your pharmacy benefit budget.

To learn more about our consulting and auditing services, please visit us at www.pbirx.com or contact us at (888) 797-2479.

Pharmacy Benefit Auditing at PBIRx

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

 

Since pharmacy costs represent nearly 40% of today's total health care costs, it is crucial for any entity that provides pharmacy benefits to its employees or members to audit all the financial discounts and guarantees stated in their PBM contract to be sure that claims are being adjudicated exactly as you agreed to in your PBM negotiations. 

Furthermore, as the cost and utilization of specialty drugs continues to rise, it is even more important to make sure that the discounts negotiated are in accordance with the terms outlined in the signed contract including Limited Distribution Specialty Drugs and new drugs that come to market. 

At PBIRx, it is our goal to make sure that the language, discounts and guarantees stated in our clients' contracts are being adjudicated accurately by the PBM, which is why we provide comprehensive pharmacy claims audits using our proprietary AuditRx® platform.

AuditRx® presents our clients with a comprehensive written report with Exhibits to provide to the PBM. Additionally, our team of experienced actuaries and financial analysts have been very successful in negotiations with various PBMs resulting in significant monetary recoveries.

The following is a brief description of the AuditRx® process, which can be annually, quarterly or monthly:

• Facilitate delivery of all PBM claims data in an electronic format to PBIRx.
• Format financial terms which are stated in the signed contract between the client and the PBM, into the AuditRx® platform.
• Provide auditing results in both summary and detailed formats on the accuracy of information such as contracted brand/generic discounts, dispensing fees for retail, mail and specialty pharmacy along with administrative fees.
• Review contract language related to PBM shared savings billing reconciliation and member co-payments in accordance with plan design and claims paid by ineligible members.
• Provide eligibility audit to be sure that claims are not being adjudicated for members no longer eligible for pharmacy benefits.

For more information on the AuditRx® program, visit us on our website or contact us at (888) 797-2479 today!