PBMs often use sophisticated technology to produce data and reports that reflect superior performance and seemingly exceed contract guarantees. These systems are prone to error and are not always designed to drive costs down. Errors and inaccurate or manipulated reports may lead to a variety of problems, such as a false sense of control, ambiguous explanations and ultimately a failure to control overspend. Unfortunately, there are also instances where a PBM is not performing up to the contractual obligations. This can result in huge dollar expenditures for a payer that may not be necessary. Auditing your PBM can help you detect, avoid and prevent these problems.
Companies usually audit their PBM a year or more after the implementation of their PBM contract. However, it’s not necessary to wait. Our innovative performance monitoring system, ClaimWatchRx, serves as an early warning system for discrepant PBM performance. It is capable of identifying trends and opportunities early, allowing you to find out if your PBM is meeting all guarantees and managing your benefit in your best interest.
Every situation is unique. Crystal Clear Rx offers a range of options and solutions depending on your business needs. Our PBM monitoring & audit system is designed to integrate with a wide variety of PBM file formats and help bring clarity to your benefit spend.
Call us today at (303) 955-7827 so we can better understand your unique needs and find out how we can help extract maximum value from your PBM contract.
Changing major benefit providers always comes with challenges. Implementing a new PBM can mean building new relationships, adjusting to new processes, learning new reports, and understanding different cost profiles that make auditing and value analysis difficult. However given proper time and management, many challenges can be prevented and the cost savings often justify the risks.
Crystal Clear Rx is a full service PBM Consultant. We will support you for the full term of your pharmacy benefit program. We can help you with PBM RFP preparation, PBM selection, advise on contract terms and negotiations, provide PBM performance monitoring, and offer PBM audits to help you through contract renewal.
Writing, preparing and evaluating RFPs for PBM can be a daunting and arduous process. Because PBMs are often inundated with RFPs, the responses they provide are very general, often vague and may not be a completely accurate representation of their resources and capabilities. This makes confidently choosing a PBM to best fit your needs time-consuming, frustrating and even stressful. Crystal Clear Rx has decades of experience writing and responding to RFPs for PBM. Our industry experience allows us to fully understand what questions to ask and how to ask them, to elicit more factual and indicative responses. When you are provided with more detailed and accurate information for comparison, the PBM selection process need not be so painful.
It makes no difference which PBM you contract with.
However, we do believe that the type of PBM contract model you choose makes a big difference (for example; traditional vs. pass-through pricing arrangements). Crystal Clear Rx works strategically and professionally with all PBMs. We carefully monitor your claims data and pharmacy benefit spend trends, then alert you and/or your PBM to potential pricing anomalies or help payers transition from one PBM to another. Our proprietary software helps quickly load extensively detailed data files from any PBM and conducts a complete analysis relevant to how claims are priced and paid. Our process provides you with clear and actionable information for better insight and allows you to generate customizable reports about your pharmacy benefit spend.
Although it may be tempting and reasonable to assume that larger PBM providers offer better savings, large PBMs and better savings are not mutually exclusive. The type of contract and pricing arrangement is really what drives overall savings and true performance. Kickbacks to providers, constant pricing manipulations and biased reporting are just a few things to consider, relevant to inflated pharmacy benefit costs. We keep an eye on all the data elements and find anomalies that may drive up your costs and proactively work with you to avoid overspend.
It depends on the way the benefit is structured. In some case Mail Order may actually cost the payer more than the same amount of medication filled at a retail pharmacy.