Pharmacy benefits consulting

Prescription drug financing and pharmacy benefits manager (PBM) arrangements can be extremely complicated. We'll help you navigate the complexity.

Milliman can help clients address the many issues surrounding pharmacy benefits. We provide a variety of services and follow-up support to help clients plan, initiate, and maintain a pharmacy benefits program. Our consultants can assist with every part of the process, including:

PBM vendor request for proposal (RFP). We help with vendor selection, including RFP development, PBM bidder selection, RFP fulfillment, proposal evaluation, and finalist selection.
PBM contracting. We help clients write, negotiate, analyse, and audit their contracts with PBMs. We bring an understanding of the ongoing changes and current cost factors in the pharmacy benefits industry and use it to help clients obtain the most favourable contracts and the best pricing possible.
Pharmacy plan design. We help clients create and analyse a robust and effective pharmacy benefits plan model that also provides flexibility and affordability for both plan sponsor and plan members.
PBM implementation oversight. Once a PBM vendor has been selected, we provide PBM implementation oversight to ensure a smooth transition to the new PBM with minimal member disruption.
PBM ongoing support and management. Our consultants can also work directly with a client's PBM to provide improved economic control and a greater focus on quality of care and service to the plan's members. This can help ensure the transparency of financial, clinical, and operational processes of the PBM operations, and also provides a way to manage cost with the integration of medical guidelines, disease management, wellness, and other clinical-based programmes. On-going support and management we routinely provide to our clients includes reporting (monthly, quarterly, and ad-hoc), attendance at PBM meetings/presentations, independent assessments of cost and utilisation statistics, and market checks for pricing terms for specialty and traditional medications.
PBM audit services. We are available to help clients audit their PBM arrangements to validate that the PBMs are meeting the contractual integrity and financial obligations. We routinely perform audits of pharmacy claims, rebates, retiree drug subsidy (RDS), prescription drug event (PDE), performance guarantee (PG), corporate compliance, and data validation.

Healthcare reform

With the requirements of the Affordable Care Act (ACA) taking effect between now and 2020, Milliman helps clients keep up to date with regulations and the resulting cost-shifting effects. Our consultants can provide an understanding of both near-term changes and longer-term implications.

Medicare Part D

We help plan sponsors gain a thorough understanding of all the choices open to them under Medicare Part D by analyzing and modeling a variety of plan options. We can also help implement and administer the selected option, and we can work with the Centers for Medicare and Medicaid Services (CMS) to qualify the plan, conduct the formulary review, and carry out other implementation-related activities. In addition, we provide:

RDS administration and support
Direct contract employer group waiver plan (EGWP) prescription drug plan application and support
800 Series EGWP prescription drug plan or MA-PD selection and support
Reconciliation and prescription PDE assessment
Compliance planning and mock auditing
Response to CMS inquiries
Data validation readiness
Data validation audits
Readiness reviews
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Pharmacy benefits consulting