prescription benefit plan auditing services
TRANSCRIPT
Prescription Benefit Plan AuditingImproving Prescription Plan Efficiencies & Plan Sponsor Compliance
Why Audit Your Prescription Plan? Discover hidden rebates or spreads to reduce
plan costs Monitor and correct improper or inefficient plan
administration through your Pharmacy Benefit Manager (PBM)
Minimize your fiduciary obligation as plan sponsor by conducting an independent, unbiased audit
Complete the financial reporting that may be required by the Department of Labor for ERISA plans and CMS for Medicare plans
Terminology PBM – Pharmacy Benefit Manager is the
prescription plan administrator Rebates – pharmaceutical manufacturer
dollars available for client or administrator as compensation
Spreads – the difference between the total rebate and what the PBM or carrier/advisor is passing along to the client
Drug Distribution Channels
How We Audit Your Plan As an independent Third Party
Administrator (TPA) we provide an unbiased market analysis of how your plan is performing compared with other PBM’s
We evaluate cost drivers and clinical errors to maximize the value of your benefit to your associates and plan sponsors
Our Audit Process Identify all rebates and or spreads and
administration fees Identify counter-indicative drugs Make sure benefits are administered in
accordance with SBC and plan document Eliminate duplicate dispensing Make sure you maintain age and gender
compliance Determine accuracy of average
wholesale pricing
Sample Audit – Huge Savings!Sample CompanySavings Analysis SummaryPRICING COMPARISON
# Claims Utilization Current Costs Our PBM Costs Savings Savings %
MAIL SERVICEBrand Drugs 358 23.20% $219,149.95 $206,508.06 $12,641.89
Generic Drugs 1,186 76.80% $96,551.57 $78,059.47 $18,492.10
Total Mail Service 1,544 $315,701.52 $284,567.53 $31,133.99 % Mail Service Utilization = 5.7%
RETAILBrand Drugs 4,961 19.60% $1,404,607.15 $1,311,573.33 $93,033.82
Generic Drugs 20,274 79.60% $558,274.69 $553,927.53 $4,347.16
Total Retail 25,235 $1,962,881.84 $1,865,500.86 $97,380.98
SPECIALTYTotal Specialty 206 0.80% $1,081,644.95 $1,045,084.34 $36,560.61 Totals 26,985 $3,360,228.31 $3,195,152.73 $165,075.58 4.90%
$165,075.58 4.90%
REBATES
Current Rebates
$15.61 PEPM Total
Select Formulary*
Per mail service brand claim $225.00 $80,550.00
Per retail 90 brand claim $175.00 $6,650.00
Per retail 30 brand claim $70.00 $344,610.00
Per specialty brand claim $500.00 $98,000.00
Totals $206,052.00 $529,810.00 $323,758.00
$323,758.00 9.60%
CLINICAL PROGRAMS
Savings Savings %
Generic Incentive - 100% conversion $134,041.37
Quantity Limits $6,560.93
Dose Optimization $4,360.68
Dispense as Written (DAW) $146,220.75
$291,183.73 8.70%
TOTAL ESTIMATED SAVINGS 23.20%
Our PBM RebateSavings %
TOTAL ESTIMATED SAVINGS from Rebates
TOTAL ESTIMATED SAVINGS from Clinical Programs
$780,017.31
TOTAL ESTIMATED SAVINGS from Drug Spend
Rebate AgreementPer Claim
Savings
Our PBM Services Pharmacy
Benefit Plan Consulting – auditing service
Pharmacy Benefit Plan Management – fixed cost per claim prescription administration and ongoing auditing
RFP Management – providing unbiased renewal process and contract reviews
Complete Benefit Plan integration – full benefit TPA with prescription management
Two PBM ModelsRebate Sharing Identify the rebate
savings and share with client on an appropriate split
Must be disclosed and will be reported via 5500 Reporting
Fee Per Script PBM charges a flat
fee per script and passes 100% of the rebates back to employer
Typical Rebate Ranges(Brand and specialty drugs only) Mail service brand claim $100-250 Retail 90 day claim $75-200 Retail 30 day claim $30-$130 Specialty claim $100-$500
Proposal Recommendations The final analysis will illustrate clinical
plan differences and cost differences with multiple PBM’s
We will recommend a PBM based on acceptable margins and level of client interaction with PBM services
Our audit fee is based on the group population and claims volume to be reviewed
Markets Groups over 100 participants- both fully-insured
and self-funded Small self-funded plans where prescription claims
data is available Collective pooled plans like workers comp,
captives or buying consortiums Companies with the big name PBM’s – CVS
Caremark, Express Scripts, Optum
How To Start? Provide as much detail as available with
claims runs from 1 month to 2 years – see list on website under service tab – Prescription Audits (www.self-funded.us)
Complete our online Audit Questionnaire Once information received it takes 3 to
4 weeks to complete the audit
Contacts Bob Miller [email protected] Doug Helser [email protected] [email protected] www.self-funded.us Phone: 844-222-3190 or 614-961-0339