Pharmacy Benefit Management (PBM) Program Reviews:

PBMs process approximately 70% of all prescriptions dispensed in the US each year.

Consolidation in the PBM industry put over 75% of the transactions in the hands of just 3 companies!

PBMs have "tricks of the trade" that most HMOs don’t know and don’t understand.

Other than the cost of hospital care, the cost of Rx is the highest cost to MCOs, with trends continuing to hover in the 4% - 6% range and with SPECIALTY Rx trends of up to 24% within major PBMs.

PBMs employ pricing arbitrage strategies that result in SPREAD being created. This spread shifts money back to the PBM above and beyond the negotiated dispensing fees and other fees factored in the PBM contracts with MCOs.

Some of the tricks to create "spread" include:

Creating their own MAC to charge at will for generics.

Using AWP definitions within the contract to keep bulk purchasing savings for themselves.

Sneaking spread provisions in the contracts rather than providing true pass-through pricing to the MCOs...for example, contracts between the HMO and the PBM require pass-through of rebates; however, the contract between the PBM and the manufacturers basically re-define would-be rebates as: administrative fees, prompt pay discounts, data fees, misc. discounts, etc. to the extent that "rebates" are small to the HMO and “rebate look-alikes” are prevalent in the manufacturer contracts and those $s are shifted back to the PBM.

NDC switching and other repackaging strategies that create artificial spread.

What can we do?

Use our proprietary database to reveal what true procurement costs are…so that you can see the extent that PBMs are creating artificial spread.

We can un-cover PBM gamesmanship and fix the issues!

We can also run your Rx claims history through our proprietary predictive modeling tool in order to identify potentially missed HCCs. Long story short, we can help to reduce your cost in your largest area of spend while also helping to increase your premiums.