Look beyond what your PBM shares: prescription claims data is a powerful tool

By Chris Hanson-Ehlinger
Wed, Feb, 05, 2014 @ 08:02 AM

iStock 000016671426SmallYour pharmacy benefit manager (PBM) collects and filters all of your plan’s prescription claims data. You may get quarterly reports but chances are they may contain only what the PBM chooses to disclose. There is much more to be gained from your data.

An experienced pharmacy benefit consulting firm has the ability to monitor PBM performance with regard to pricing guarantees, utilization cost savings measures and which PBM provides the best services with the least expense for your particular plan. Here are three ways to transform your data into information that improves your plan performance and puts money in your pocket.

Validate pricing guarantees

At the close of each contract year, your PBM calculates its over- or under-performance with respect to contractual pricing guarantees. Instead of accepting the PBM’s analysis as accurate, it’s advisable to validate that the calculation is correct. Audit models analyze the PBM’s actual performance in comparison to contractual guarantees. And while this calculation may confirm the PBM’s analysis, there are many cases where reimbursement due to the client is much greater than the amount reported by the PBM.

Leverage utilization information

Use your data to examine current utilization. Detailed analyses compare your plan’s performance against a reference point based on a broader book of business. For example, you can examine statistics related to generic fill rate, plan cost, specialty drug utilization and distribution channel breakdown. Doing so lets you identify anomalies, build strategies to address them and measure impact over time.

Negotiate beneficial contracts

Information is your most powerful asset when selecting an appropriate PBM and negotiating a competitive contract. Your prescription claims data can be trended to forecast future drug spend and provide an equitable comparison between competing vendors. It’s a critical step in minimizing your pharmacy benefit expense.

There are myriad advantages to mining your prescription claims data, from validating PBM calculations to rigorous contract negotiation. As the number of prescriptions and patients continues to increase, using your data to predict spend and determine cost savings is ever more essential. A qualified prescription drug plan consultant can help you analyze and deliver unbiased, actionable information to better manage your prescription drug benefit.

Steve Baumgardner, consulting services leader at The Burchfield Group, manages Burchfield’s employer consulting team, as well as the consulting operations team that is focused on RFP development, financial analysis, and contract negotiations. For more information on this topic or related matters, please call the The Burchfield Group at 800-778-1359 or send us a note (http://www.burchfieldgroup.com/contact/).

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