Pharmacy Benefits

Directorship and vendor oversight

This is one of our most popular services and a great fit for employers of all sizes and industries. We provide oversight and help plan pharmacy benefits.

Our services include:

• Ongoing advocacy on any issues related to pharmacy benefits
• Annual pharmacy strategy development
• Extension of benefits team for managing pharmacy benefit managers (PBMs) or health plans
• Benchmarking and recommendations on vendors and programs
• Implementation support to ensure smooth transitions and integration with third-party vendors
• Financial and benefit audits to maintain compliance and accuracy
• Vendor management and issue resolution for members

Strategy and road maps

Our services include benchmarking plan design to assess whether your pharmacy benefits are competitive and aligned with industry standards. These services are best suited for employers that have in-house staff to manage vendors but need an annual assessment based on marketplace changes.

Our services include:

• Benchmarking plan design — ensures benefits are competitive
• Identification of key cost drivers — helps manage and reduce expenses effectively
• Clinical overviews — ensures care provided meets high medical standards
• Compliance and disease management
• Pipeline analytics — watches for new therapies on the horizon and identifies potential plan specific impact and potential utilization management and coverage approaches
• Innovation — identifies new trends, programs, vendors and innovations in pharmacy care to allow for consideration of progressive opportunities for benefit plans

Specialty pharmacy

Specialty drug costs continue to accelerate, trending at 15% to 20% and exceeding up to 60% of total pharmacy spend for many employers. With emerging high-cost drugs, gene and cell therapies entering the market, you need strategies to control costs. Our pharmacy experts can analyze your utilization and recommend strategies specific to your organization. We recommend an in-depth review of specialty spend annually given the growth of million-dollar therapies.

Our services include:

• Specialty dashboard — provides real-time information and data to allow for changes in pharmacy benefits strategy
• Diagnostic services — finds inefficiencies and opportunities for strategic decision making, improving overall program effectiveness
• Vendor summits — brings together key stakeholders to foster collaboration, align goals and ensure that all vendors are committed to meeting your organization’s needs

Pharmacy financials

Our services improve your pharmacy benefits through benchmarking, market analysis, competitive renewals, strategic marketing initiatives, assessment of alternative pricing structures and vendor partnership models and diligent contract negotiations. We’re successful in negotiating better terms, resulting in significant value to your organization.

Our services include:

• Market checks — ensures your contract has best-in-class pricing
• Competitive renewals — reviews current contract terms and ensures your organization has the best negotiated terms and financials when renewing with an incumbent vendor
• Competitive marketing initiatives and requests for proposals — manages the process to attract the best vendors and foster a competitive environment that encourages high-quality services at competitive prices
• Contract negotiations — secures the best terms for your organization, focusing on cost efficiency, service quality and clear and meaningful measurement of service and financial performance guarantees

Auditing and governance

Our services analyze accuracy in pricing, rebate performance, drug coverage and plan-design rules. Most of our clients engage in pharmacy audits at least once every three years, while some audit their PBMs annually.

Our services include:

• Discount and fee validation — ensures that you receive the agreed-upon financial terms, negotiated prices and fees with PBMs and vendors, holding them accountable and transparent
• Drug price variance analysis — benchmarks against acquisition cost and other models
• Rebate guarantees and pass-through audit — ensures vendors are correctly passing savings to you in compliance with contract commitments
• Plan benefit design — includes assessing the accuracy of claims performance relative to the expected rules for the plan’s formularies, copay structures and other pharmacy benefits that match clinical effectiveness and ensure compliance with plan parameters
• Clinical and operational reviews — assesses the efficacy and efficiency of your pharmacy benefit programs
• Pre-implementation audit — validates the readiness of the PBM to effectively administer a new plan or significant plan change updates accurately in their claim adjudication system to find inaccuracies before members begin the new benefit

Pharmacy vendor solutions

Our services go beyond PBMs to offer support with alternative vendors. We’ll analyze investment feasibility and return on investment, manage vendor procurement, assess operational effectiveness and outcomes and negotiate contracts to align with your strategic goals in pharmacy benefits management. These may include PBM overlay, pharmacogenomics, onsite pharmacy, metabolic health, mental health and fertility vendors.

Our services include:

• Feasibility and return on investment analysis — evaluates potential investments or changes in your pharmacy benefits plan
• Vendor procurement — manages the entire process from vendor selection to finalizing agreements
• Operational and outcomes assessments — measures how well your PBM works by looking at how it runs, how patients progress and looks for areas to improve
• Contract negotiations — enables us to secure favorable terms that align with your strategic goals
• Our Comprehensive Condition Care offering is designed to help you create a treatment strategy to address diabetes and obesity, using our analytic tools and coordinated team of subject-matter experts across pharmacy, health, equity and wellbeing and health analytics

Rx Collaborative

The Rx Collaborative group-purchasing employer coalition offers a full set of services for employers with more than 1,000 employees. Our deal terms, along with an active pharmacy management strategy, can save your organization up to 25% of current drug costs.

Attune Rx

Attune Rx is a comprehensive pharmacy benefits solution for small to midsize employers with less than 1,000 employees. In partnership with RxBenefits and with our oversight, we provide you with pharmacy benefits you might not receive in the direct market.

Connect MedRx

Connect MedRx offers a carve-in pharmacy solution for self-funded employers with more than 250 members. Anthem is the medical carrier and CarelonRx is the PBM. It features competitive pricing and favorable financial terms, including rebates and network discounts. Additionally, we conduct an annual market check to ensure continued competitiveness. Our approach saves money by working with pharmacy and medical drug management programs to reduce overall healthcare costs while still providing high-quality care.

Pharmacy benefit overlay partners

We’ve partnered with two top pharmacy benefit overlay solutions, Rx Savings Solutions and Scripta Insights, to supplement PBM services. Members receive cost-saving recommendations that help reduce expenses and encourage greater adherence to prescribed treatments. Improved adherence is tied to better clinical outcomes. This is an ideal solution for employers looking to address member affordability and improved clinical concierge support. Additionally, support from our pharmacy specialists is included, providing expert guidance and assistance to ensure the best possible service and results.