Pharmacy Benefits Management Consulting

Most employers overpay their PBM without knowing it. We start every engagement by pulling apart your current contract and twelve months of claims and rebate data to find where the money actually goes. This no-risk review carries no cost and puts no current vendor relationship on the line.

• Pinpoint contract terms that are costing you money today
• Score your PBM’s financial performance against the current market

Formulary decisions shape both member health and plan spend. Our pharmacists and clinical consultants build formulary and benefit designs around your population’s actual drug utilization, not a generic template pulled off a shelf. Every recommendation accounts for where biosimilars and specialty drugs are headed next.

• Build formularies around your population’s real drug utilization data
• Capture rebate value without shifting cost onto members

Switching PBMs ranks among the biggest financial decisions a plan sponsor makes, and most organizations run this process every three to five years. We manage the entire RFP process, a piece of PBM consulting most benefits teams don’t have the bandwidth to run in-house, and pit dozens of PBMs against each other for your business.

• Score competing PBM proposals against client-specific performance guarantees
• Negotiate contract terms that hold up after the ink dries

Once a PBM is in place, someone still has to hold them to the promises in that contract. Our pharmacy benefit consultants step into that role, running day-to-day vendor oversight so implementation issues, member escalations, and performance gaps get resolved before they cost your plan money.

• Lead pre- and post-implementation audits to catch setup errors early
• Resolve member-specific issues directly with the PBM on your behalf

Effective pharmacy spend management depends on catching cost drift before renewal, not after. Our health actuaries and clinical analysts track your claims data on a rolling basis so utilization shifts and trend spikes surface well before your annual renewal date.

• Flag high-cost claims for clinical review as they happen
• Confirm PBM financial guarantees hold up against actual quarterly results

Specialty and high-cost drugs often bill through the medical plan instead of the pharmacy benefit, where they can slip past standard pharmacy oversight entirely. Our nurses and pharmacists review those medical claims directly, closing a gap that leaves many plan sponsors exposed.

• Identify high-cost drug claims hiding inside medical plan data
• Step in with clinical and financial interventions before costs escalate