Pharmacy benefits are one of the fastest-growing segments of the healthcare dollar, but pharmacy benefits manager (PBM) arrangements can be extremely complicated. What's more, new healthcare reform laws now affect the prescription drug arena, and the ongoing requirements of Medicare Part D can pose a significant administrative burden. Milliman's pharmacy benefits consulting services can help clients address all these issues and more.
Healthcare reform
As the requirements of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 take effect between now and 2020, Milliman can help clients keep up to date with new regulations and the resulting cost-shifting effects, and can provide an understanding of both near-term changes and longer-term implications.
PBM arrangements
Milliman can help with PBM vendor selection, implementation, and oversight processes. Our insight and products will provide a unique approach into how and where the pharmacy dollars are being spent.
We help clients write, negotiate, analyze, 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 favorable contracts and the best pricing possible.
Milliman specialists are available to help clients audit their PBM arrangements to validate that the PBMs are meeting the contractual integrity and financial obligations.
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 programs.
Pharmacy plan design
We can help clients create and analyze a robust and effective pharmacy benefits plan model that also provides flexibility and affordability for both plan sponsor and plan members.
Medicare Part D
By analyzing and modeling the effects of various options, Milliman can help clients gain a thorough understanding of all the choices open to them under Medicare Part D. We can also help implement and administer the selected option, and 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. Our services also include:
- Retiree Drug Subsidy (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 drug event assessment
- Compliance planning and mock auditing
- Response to CMS inquiries
