Strategic Solutions for Better Medical Insurance
Overview
Regency Benefits Group (RBG) has unique expertise in pharmacy benefit programs with dedicated resources to consulting on the management of these programs.
With more than 15 years of collective experience in this highly complex industry, RBG provides plan sponsors and health plans with an unparalleled evaluation of its pharmacy cost.
The pharmacy benefit management (PBM) industry is constantly changing. With these changes, there are continuously increasing opportunities to achieve improved financial terms and conditions, resulting in lower overall pharmacy costs.
RBG recognizes that pharmacy costs are a growing portion of the total cost of health benefit programs. To ensure pharmacy costs are properly managed, a thorough review of the program is necessary to optimize the value of the benefit, and that the PBM service model matches the unique needs of the customer.
With a thorough understanding of the industry’s pricing optics, contracting strategies, and clinical, administrative, and profitability strategies, we are well-positioned to offer the following services.
Strategy Development and Current Pharmacy Review
The initial part of RBG’s strategy development is to evaluate and validate the client’s current performance. RBG’s proprietary process compares a client’s stated performance from the existing pharmacy vendor versus the actual performance.
This benchmarking creates a few opportunities: first, it will assess if the current vendor has been adhering to their contractual terms and conditions; next, it creates the foundation for the development of a multi-year strategy. With a firm understanding of past performance, we build a strategy based on the stated goals and objectives.
Additionally, RBG takes into account the need to maximize the underperforming components of the customer’s program and to ensure that those areas that are performing well continue to do so.
Proactive Management and Guidance
RBG keeps current with industry trends to ensure a client’s pharmacy benefit is up to date.
Customers have access to our team to answer questions concerning their pharmacy benefits and the industry in general. We participate in the regular PBM vendor meetings, monitor compliance with a customer’s PBM contract, and perform audits on the critical contractual commitments made by the vendor.
This integrated approach enables pharmacy benefits to stay ahead of the curve in terms of both cost and performance—especially in light of the ever-changing pharmaceutical industry with regard to new drugs, reclassified drugs, and increased access to generic drugs.
Pharmacy Program Design
One of the most effective means of controlling pharmacy costs is by properly aligning the design of the pharmacy program.
With increased consumerism, pharmacy program designs are an important component of aligning member and plan sponsor interests. RBG provides the necessary guidance and financial modeling to create the plan design(s) that will allow the customer to meet their stated goals.
RBG’s design process will take into account a thorough evaluation and cost modeling around the following components:
• Network Options
• Clinical Programs
• Utilization Management Programs
• Inclusions and Exclusions
• Mail Order Usage
• Copay Alignment
• Formulary Options
• Specialty Pharmacy Programs
Market Evaluation, Recommendations/Contract Negotiation, and Implementation
There are numerous PBMs and health plans that administer pharmacy benefits on behalf of plan sponsors. The evaluation of these vendors and their approach to managing pharmacy benefits is critical to establishing a long-term cost-effective program.
RBG provides a customized procurement process to meet the goals of the purchaser. This process evaluates the vendors’ cost structures/profit margins, as well as the PBM’s service model, and their ability to handle the client’s unique needs.
Additionally, a critical element of the process is to evaluate the clinical capabilities of the PBM and their ability to integrate with the selected medical vendor(s).
Lastly, RBG reviews the PBM’s contracts with the pharmacy networks and the drug manufacturers along with a specific emphasis on specialty drugs and the related clinical programs and cost controls available.
As part of this process, RBG will:
- Perform a complete evaluation of the pharmacy market specific to the client’s stated goals and objectives including scoring the responses to identify the selected finalists
- Provide an executive-level summary of the initial outcome of the procurement process
- Conduct price and service model negotiations with the selected finalists
- Provide a summation of the findings for consideration
- Review the proposed contract of the selected partner to ensure the final negotiated terms are properly captured and implemented
RBG’s process will demystify the numerous tactics and complexities of PBM pricing to achieve a favorable financial outcome for the client.
Pharmacy Review and Validation
As an added service, RBG provides detailed auditing of claims processed by a customer’s PBM on a regular basis to ensure the PBM is honoring the terms of its agreement (i.e. terms of pricing, plan design administration, and overall plan performance).
RBG provides an industry-leading analysis of the data provided by pharmacy vendors. All claims will be electronically repriced and cross-referenced to independent data sources.
Through this process, RBG will be able to identify the financial values achieved by the plan and validate that the claims and financial guarantees provided for in the contract are being achieved.
This electronic reprocessing of claims is critical to ensuring PBM contract compliance. RBG’s proprietary repricing logic covers all aspects of the PBM pricing model, including:
• Full NDC Codes
• AWP Adherence
• Days’ Supply Pricing
• Brand and Generic Definitions
• MAC Pricing
• Zero Balance Claims
In addition, we will analyze and report on other non-claim level activity, including overall formulary guarantees, DUR guarantees, and service model performance guarantees. At the completion of the audit, RBG will provide an overall analysis of the total plan cost versus the contracted terms.
We will provide clients with an executive-level summary of the findings, and work with the PBM to reconcile any differences in actual plan cost versus the audit findings.