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Are you getting the service, savings and performance you expect from your PBM?


Discover how to manage your next RFP with confidence to secure better PBM rates, service and innovation programs. Watch this short, on-demand PBM RFP webinar

Don't let PBM mistakes put you at risk!

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Watch this short, on-demand audit webinar to learn how to protect yourself from unexpected liability and why it's important to create a PBM audit strategy. 

Are you completely prepared to migrate your prescription drug benefits to a new claims platform?


PBMs process millions of claims, not just yours. One human error can impact your bottom line, cause member disruption and cost you hours of administrative time. Learn what's at stake and how to best prepare for migrating your pharmacy benefits in this informative, on-demand webinar

Health Plan Insurer Blog

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Data validation data element changes and what to expect in 2015 audit

The 2014 data validation audit has come to a close and I hope it was successful for you!

OIG reveals prescriptions for hospice enrollees paid in duplicate

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The Office of Inspector General (OIG) found that more than $33 million in prescription drug claims for hospice enrollees were paid twice in calendar year 2009: once under Medicare Part A and again under Part D. In response to the findings, Centers for Medicare and Medicaid Services (CMS) issued final 2014 guidance aimed at mitigating duplicate payments. The most significant change for sponsors is that, beginning May 1, plans should place beneficiary-level prior authorization (PA) requirements on all drugs for beneficiaries who elect hospice care.

Are your PBM pricing discounts seriously underperforming?

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Pricing guarantees are tricky. Even with a traditional arrangement (locked-in brand discounts and dispensing fees) you still have to account for generic pricing and aggregated guarantees often can’t be calculated until the end of the year. Measuring generic effective rates in the middle of a pricing term is difficult, too, and your PBM may argue that any sign of underperformance is not a cause for concern because the term is incomplete.

Adjust your drug plan strategy to manage specialty medication costs

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Brian Bullock, Founder and CEO at The Burchfield Group, presented his perspectives on prescription drug innovation at the Minnesota Health Action Group’s 7th Annual Leadership Summit, Moving Forward in Uncertain Times, on February 21.

Last chance to voice your opinions about proposed 2015 CMS changes

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In January CMS announced it proposed 2015 policy and technical changes for Medicare Advantage (MA) and Medicare Advantage Prescription Drug (MAPD) programs. Plan sponsors have until March 7 to provide comments and feedback about the changes. Proposed changes apply to:

Use Standard’s weighting to prioritize CMS data validation efforts

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It’s easier to prioritize your efforts and meet CMS requirements when you understand the seven Medicare Part D standards and how they are weighted.  Keep in mind the following as you prepare for the next data validation cycle.

Simplify reporting for data validation Standards 4-7 with a single policy and procedure document

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In some cases, one document can do the work of validating several standards, saving you time and effort. For example, the guidance around validating Standards 4-7 shares common language about how to meet the requirements:

No change to CMS Cycle 2014 SNP reporting requirements

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Even though SNP has the fewest data elements, it seems to generate the most questions. After multiple changes since 2011, the specifications are starting to align.

Resolve gaps and risks before your prescription drug plan goes live

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A smooth and seamless transition is no guarantee when you offer a new prescription drug benefit, change your existing benefits or move from one PBM vendor to another. Much can go awry. The most common repercussions include eligibility issues: member coverage is termed; claims are denied; copays are miscalculated. A pre-implementation audit can help protect your investment.

Three ways to improve Standard 3 data reporting accuracy

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Remember last year when CMS issued last minute guidance that required plans to achieve 100 percent accuracy for Part C and Part D grievance sections? That small change made a big impact on scores (and not in a good way). Many plans suffered because of the new guidance. Standard 3 is all about data submission. Here are three easy ways to work toward 100 percent accuracy on all your reporting sections.

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