January 24, 2024

For plan sponsors, detailed insight into their pharmacy benefit plan through a no-risk assessment is pivotal for controlling costs while maintaining a high-quality plan for members. In the opaque world of PBMs who play “shell games,” enlisting the help of a pharmacy benefit consultant gives employers, brokers and TPAs information about how their PBM is performing.

A no-risk assessment by a pharmacy benefit consultant is the first step toward unlocking significant savings and providing a roadmap for how to improve your pharmacy benefit plan. But how does this process work, and what specific benefits does it offer?

1. In-Depth Contract Analysis: Unearthing Hidden Opportunities

The foundation of a no-risk assessment lies in a detailed analysis of your PBM contract. At Innovative Rx Strategies, our team of PBM experts scrutinize the fine print, identifying weak areas of the contract that make it less effective. They delve into pricing guarantees, definitions and service level agreement — pinpointing instances where contracts use vague terms and conditions which allow a PBM to underdeliver their commitments.

2. Historical Claims Data Review: A Comprehensive Look Back

Another integral part of the assessment is a review of the plan’s previous year of pharmacy benefit claims data. This medical claims surveillance provides a clear picture of spending trends, inefficiencies and overpayments. By highlighting these patterns, Innovative Rx Strategies can identify specific areas where the PBM has underperformed. Additionally, the claims analysis helps plan sponsors understand if their pricing is market-competitive compared to similar entities of their size. This detailed breakdown of overall competitiveness is the foundation for future cost-saving negotiations with a PBM.

3. Clinical and Financial Synergy: Balancing Cost-Savings with Quality Care

Effective pharmacy benefit management is not just about cutting costs — it is about finding the balance between financial strength and quality for members. A no-risk assessment includes an evaluation of the plan’s clinical robustness and their utilization of cost-saving mechanisms such as patient and copay assistance programs. These programs are crucial in managing costs while ensuring that members have access to the medications they need.

4. Building a Strategy: Setting the Stage for Future Savings

With the insight gained from the contract and claims data analysis, Innovative Rx Strategies can present its findings to the plan sponsor and discuss the potential for negotiating improvements to the pharmacy benefit plan. This may involve negotiating better pricing and contract terms with the plan’s incumbent PBM or issuing a comprehensive RFP to multiple PBMs to drive competition. The goal — negotiate a vastly improved pharmacy benefit plan that is not only cost-effective but also clinically robust and tailored to organization’s specific needs.

5. The Impact: Peace of Mind

Organizations that undergo no-risk assessments improve their ability to manage their pharmacy benefits proactively before rising costs become a problem. Our assessments typically identify anywhere from 15-25% in savings on pharmacy benefit costs, resulting in millions of dollars of cost-reduction for plan sponsors and their members.

 

Having an analysis conducted does not necessarily mean that you need to make sweeping changes to your plan or PBM. It does, however, provide you with the peace of mind that you are maximizing your leverage with finite resources.

If you are interested in a risk-free step toward managing your pharmacy benefit costs, contact us today!

 

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