Pharmacy Analytics and Contract Negotiations

In the deregulated environment of pharmaceuticals, it is more important than ever that employers have pharmacy specialists who understand how to see through the lack of transparency. We understand the industry profit-taking strategies and we know how to aggressively protect employers from the lack of transparency. By understanding key contract language and nuances that most employers and brokers overlook, we are able to create true 100% pass-through contracts and audit rights that allow the employer to follow the revenue trail from the manufacturer, wholesaler, PBM, etc.  With increasing competition in the pharmacy industry, we are also able to determine where a traditional spread contract will be more competitive on a net-cost basis, and work through strategic RFP processes to gain advanced transparency even within the traditional spread contracts. We offer custom formulary management and active clinical management strategies that help employers stay out front of industry changes and reduce their risk of industry gamesmanship. With our direct access to the AWP published pricing databases, our pharmacy audit programs further help hold the industry accountable to meeting performance guarantees.

Our actively managed pharmacy programs consistently yield upwards of 15% savings on overall pharmacy spend when moving from a traditional pharmacy program.

New! Specialty Pharmacy Cost-Containment Model

Our team of consultants have developed a very refined approach to specialty pharmacy in collaboration with a team of industry pharmacists and specialty pharmacy experts. Our unbundled specialty pharmacy model leverages the best of all worlds by combining high-volume rebate aggregators with independent dispensing, administration, and clinical management. Unbundling the components and leveraging the best in class of each, combined with active management of the specialty pharmacy, has enabled us to develop an extremely competitive specialty pharmacy model that is keeping our clients out front of the industry’s rapidly exploding specialty pharmacy cost trend.

New! Active Generic Drug Management

Over the past few years, health plans have focused on moving utilization from brand name to generic. While this strategy was an effective way to reduce some of the high cost drug spend, with more drugs moving generic, the next generation of opportunity outside of specialty drug management lies in actively managing the generic drug utilization. The variability between certain generic drugs in the same therapeutic class can be significant, depending on volume. Steering volume to prefer lower cost generics in the same therapeutic class is one more way for employers to manage their pharmacy claims spend over the long-term. Our actively managed programs provide ongoing analytics and proactive management of these opportunities.

Fully Integrated Active Management of Drugs Run through Medical

Our direct contracting strategies include one-off contracts whereby we may negotiate a specific drug for a specific plan participant that is running through the medical plan. Our appointed pharmacists help us evaluate the true acquisition costs of the various drugs, which enables us to evaluate the spread and determine how much negotiating room we have with the provider. We also identify whether the provider has access to 340(b) pricing or GPO pricing so that we can more accurately identify the spread on those contracts and negotiate in the best interest of our employer groups.

Our data analysts systematically run monthly reports on our entire book of business to determine which of the drugs running through the medical plans could otherwise be negotiated directly with the provider or by steering it through the pharmacy plan.

Unlike the TPAs who typically charge a percent of savings for these services, we simply provide this service as part of our standard fee-based, actively-managed health plan model. Our costs are very much in line with the traditional broker model, but our goals is to offer more actively-managed solutions.

New! Actively-Managed Pharmacy Alert Programs

Our consultants are always looking for new ways to manage costs, increase care quality, and improve outcomes and experiences for plan participants. One of the most recent additions to our actively-managed health plan model includes monitoring of pharmacy alerts. Where we can identify that there are potential duplicate therapies and/or moderate to severe interactions, we are actively engaging in pushing this data and information back to the PBM and/or coordinating with the primary care physician of the member who may have risk exposure (for plans who adopt this level of intervention and have the appropriate HIPAA protection in place).

In this way, we are not only focused on saving the plan costs of potential overlapping utilization or claims associated with high risk drug interactions, but we are also focused on concierge service for members to ensure they are being taken care of at the highest level possible and that their primary care providers are fully informed as to possible drug interactions. Below is a sample report illustrating the type of information we are tracking by primary care physician for the clients who elect this active management at no additional cost.