Pharmacy Benefit Management
Why Pharmacy, Why Premier?
Pharmacy benefits are the most widely utilized aspect of an employer’s current benefit plan. Nearly half of a company’s membership uses these benefits every month. Depending on the age and health of plan membership, pharmacies fill an average of 12 – 35 prescriptions per member over the course of a year. Furthermore, specialty pharmacy drugs are a dominating force in the market, comprising up to 30% of pharmacy plan spend on average, while only being utilized by 1% of total membership. More than half of the drugs on the FDA’s approval pipeline are specialty drugs and are expected to be 50% of pharma-spend by 2017.
As an employer, it is crucial to understand these and other factors that contribute to the steady increase in pharmacy costs. By addressing the necessary issues related to a pharmacy benefits package, Premier can help traverse this complex and expanding market to arrive at a cost-effective and efficient solution. Most consultants fall short when working with a client on their projected pharmacy costs and requirements simply due to the consultant’s lack of experience and expertise. Premier’s team, which includes an onsite pharmacist, has unique insight into PBM contracting, claims processing and healthcare data analytics, and we use this to tailor our efforts to an employer’s specific needs.
At Premier, we pride ourselves on providing superior service to our clients by utilizing a highly diverse group of individuals who have the current industry tools and resources to provide you with expert knowledge and engagement in all aspects of the healthcare industry. Our dedicated professionals work with you to minimize the impact of rising pharmacy costs.
Meet the Leadership Team
Ted Butler has over 30 years of healthcare consulting experience including 18 years working for a PBM. Ted has the insider’s eye on how PBMs make their money and can help you to keep their margins reasonable and transparent. He is committed to using his aggressive strategies to get Premier clients the best pricing on their healthcare benefits. Ted’s expertise includes sales, goal leadership, marketing and retention in the insured and self-insured markets. He has been instrumental in analyzing pharmacy benefits management programs. As former Senior Vice President of Sales at Independent Health, Ted has led initiatives regarding claims paying platforms, reporting and analytics, rebate processing software and drug manufacturer contracting. In addition, he has managed pharmacy network contracting, mail order pharmacy contracting, specialty pharmacy contracting and overall MAC pricing strategies.
Analytics is the key to being able to assist you in better understanding your prescription benefit and the utilization patterns of your group as well as understanding the financial components of how the PBM is processing your claims. Analytics tools are the backbone of auditing and reconciling the financial terms of your PBM. Chris Purtell, Premier’s Director of Information Systems, has built his department to have the required PBM-specific capabilities to effectively monitor your plan.
What Can We Accomplish Together
With the staged implementation of the Affordable Care Act, the landscape of the healthcare industry has changed drastically for employers and will continue to do so in the future. Maximizing the effectiveness of your pharmacy program has never been more relevant.
Premier’s team brings a comprehensive level of experience and expertise from every sector of the healthcare administration sector (i.e. working for Health Plans, insurance companies, PBMs and Pharmaceutical Companies). Our Pharmacy Consulting Services illustrate the operational scope of Premier Rx:
- PBM and specialty procurement
- Clinical guidance and reviews
- PBM strategy development
- Specialty pharmacy management
- PBM auditing, oversight and contract management
- Medicare Part D compliance and audit support
- Sales and marketing support for commercial health plans
- PBM benchmarking and reporting
- Governmental entity specialization
Custom RFP Evaluation and PBM Procurement
Premier’s interests are strongly focused on the financial well-being and physical health of our clients and members. By ensuring that our clients are working with the most clinically astute and financially secure PBM, we are also ensuring that the PBM will continuously address the client-specific needs. In order to guarantee this, our team performs extensive PBM analysis and RFP customization to define and manage the needs of the client with the program that suits them best.
RFP evaluation is a fundamental aspect of the PBM procurement process, and one in which Premier’s associates excel. Premier’s expertise comes from our hands-on industry experience and is demonstrated by our ability to analyze membership-specific data across various qualitative and quantitative fields, identify an individual PBM’s strengths, weaknesses and abnormalities, and work with a client to customize the RFP. We will negotiate on your behalf to ensure an optimal contract and price point that best serves you. Because of our insider knowledge and perspective, we are confident in our ability to cut into the PBM’s margins and save you money.
Medi-Span: Creating a Transparent Pharmacy Benefit Manager
The initial contract is just the first step in proactively managing your Pharmacy costs. Premier’s strategy includes plan options, cost management goals and audits and reconciliations that assist in reducing these cost continually during the course of your contract by utilizing the Medi-Span database. Medi-Span is an industry-leading resource for prescription and over-the-counter drug information and drug interactions. Medi-Span continues to offer authoritative drug databases in a variety of formats, including clinical decision support and disease suite modules, application programming interfaces and stand-alone software applications.
With Medi-Span Premier has the ability to monitor prices of prescriptions your members use which will assist us in future strategy considerations. The operational environment of a PBM is purposefully opaque because their revenue depends on the unseen difference between the manufacturer’s discounted prices at which they purchase drugs and what you pay for those drugs at retail. This up-to-date information, coupled with our inside knowledge of PBM strategies, guarantees your pharmacy costs will always remain in check.
PBM Auditing, Oversight and Contract Management
Auditing and oversight are critical to the operational effectiveness component of any business transaction. These tools verify that both parties are working in good faith and that any incentivized individuals and entities do not to violate any contractual obligations. This is especially true in managing PBM relationships.
PBMs historically have not been transparent in their operations and use their flexible traditional business model and the ever-changing topography of the industry to sway the status quo in their favor. By periodically reviewing a PBM’s functionality and by performing contract compliance audits, we are transferring the power previously held by the PBM to you and are safeguarding your financial and membership interests. We will keep pricing protocols and plan design parameters under control and will ensure that prescription claim adjudication does not stray from the agreed upon contract terms. These audits do not always yield recovery of plan dollars but will present you with a more detailed understanding of your contract with the PBM.
In recent years, specialty pharmacy has become the focus of the pharma industry. The FDA’s approval pipeline is being dominated by specialty medications (nearly 50% of drugs pending approval are specialty), and these are projected to be roughly 50% of Rx spend by 2017. Even with this immense overhaul of the pharmaceutical industry specialty drugs, most specialty pharmacy plans do not properly address the various implications for employers with regard to mitigating these costs through the retail/mail order prescriptions and medical benefit plans.
The mix and type of medications utilized vary significantly across every employer group. This is by design, as specialty pharmaceuticals are meant to target niche markets in any population. The inherent complications that arise with utilization of these kinds of prescription drugs are difficult to mitigate on your own, and having the right consultant is imperative to the success of your plan and the health of your members.
With our expertise in designing, implementing and managing an integrated specialty pharmacy benefit and utilization management program, we can lead you through the intricacies of maintaining an educated understanding of your membership’s specialty medication utilization and mix, as well as the costs associated with them. The approaches for non-specialty pharmacy drugs have long been established in the market. However, diverse new strategies surrounding specialty drugs are emerging across the industry all the time. As your consultants, Premier’s team will diligently work to establish patterns and identify trends in specific specialty medication spend, utilization and mix to find the plan that best satisfies the needs of your unique demographic composition and budget.