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Prescription Plan Auditing Saves 23
- 1. Prescription Benefit Plan Auditing Improving Prescription Plan Efficiencies & Plan Sponsor Compliance
- 2. 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
- 3. 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
- 5. 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
- 6. 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
- 7. Sample Audit – Huge Savings! Sample Company Savings Analysis Summary PRICING COMPARISON # Claims Utilization Current Costs Our PBM Costs Savings Savings % MAIL SERVICE Brand 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% RETAIL Brand 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 SPECIALTY Total 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 Rebate Savings % TOTAL ESTIMATED SAVINGS from Rebates TOTAL ESTIMATED SAVINGS from Clinical Programs $780,017.31 TOTAL ESTIMATED SAVINGS from Drug Spend Rebate Agreement Per Claim Savings
- 8. 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
- 9. Two PBM Models Rebate 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
- 10. 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
- 11. 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
- 12. 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
- 13. 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
- 14. Contacts Bob Miller bmiller@self-funded.us Doug Helser dhelser@self-funded.us info@self-funded.us www.self-funded.us Phone: 844-222-3190 or 614-961-0339