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Whether you are a commercial plan offering fully insured and self-insured drug programs, a Part D Plan, a Medicaid Plan or an Accountable Care Organization, the bottom line is you need a Pharmacy program that is operating at maximum effectiveness.
The Solid Benefit Guidance (SBG) team brings complementary experience and expertise from every corner of the managed care sector. Our team is comprised of industry experts with experience working in Health Plans, PBMs and Pharmaceutical Companies. Together we can develop an action plan that will help your Pharmacy Program operate at maximum effectiveness.
Solid Benefit Guidance (SBG) offers the following Pharmacy Consulting Services:
Medicare Operational Support

SBG’s subject matter experts have worked in a multitude of capacities within Managed Care plans and understand the intricacies and challenges that health plans face. We work collaboratively with our clients to efficiently improve their operational excellence.

Implementations

Whether you are transitioning PBM’s or are new to utilizing a PBM for services, SBG’s expertise in PBM oversight and management will guarantee a successful implementation. We work collaboratively with your internal partners to project manage the process and ensure all services are implemented to meet CMS requirements.

Operational Analysis/Process Improvement

Our pharmacy experience in Managed Care gives us the expertise to analyze a health plans pharmacy operations and identify gaps in meeting both Medicare and Medicaid regulations. SBG’s subject matter experts will support the remediation and process improvement to optimize operational efficiencies. We will identify needs for additional internal support as well as restructuring of departments and overall organizational development.

Interim Staffing

SBG has experienced professionals in both compliance and pharmacy that can serve as temporary staff to assist you during staffing resignations, leave of absences, organizational growth periods or operational issues requiring additional hands.

PBM/Specialty Procurement

SBG is one of the only consulting firms that understands how to effectively manage a health plan PBM RFP for both traditional PBM services and specialty pharmacy because:

SBG negotiates the best deal for your Health Plan

We take into account the financial, operational and clinical aspects of an offering to negotiate the best deal for your Plan.

SBG has insider knowledge

We bring insider knowledge of pricing techniques, clinical programs and PBM operations, to secure and provide ongoing management support and oversight to achieve the best outcome for your pharmacy program.

SBG enacts contract negotiations concurrently with the RFP process

Our RFP process for both traditional and specialty procurement calls for executable contracts to be negotiated concurrently with the RFP process. By reading through the fine print and uncovering potential “pricing optics” up front, we will ensure that the deal our clients are agreeing to is clearly understood and that the selected vendor contract is built from a high level of integrity from inception.

SBG knows all the right ways to approach the contract

  • The right questions to ask
  • The right definitions
  • The future issues that need to be accounted for
  • The right contract language to secure
  • The right operational, performance and financial guarantees that will support the underlying value of your Pharmacy program

SBG has the right controls on the specialty drug list

We know how to place the right controls on the specialty drug list with regards to existing products and new-to-market products. We do this by confirming that:

    • Your specialty list has the proper controls so that medications will only be procured from a specialty pharmacy if:
      • Specialized handling or services are required or
      • The medication has a lower cost through specialty pharmacies
    • Cost components and clinical considerations that are often overlooked on the medical benefit are taken into account.
PBM Auditing/Oversight and Contract Management

At Solid Benefit Guidance, we believe the audit and business review function is critical to any successful PBM relationship and will undoubtedly yield financial benefits the next time you are at the negotiating table — especially when someone is writing checks out of your checkbook!

The PBM industry can often capitalize on the constant movement within their business model to maximize their profits in certain contract “gray areas.” While investigation of these gray areas does not always result in audit recoveries, understanding these contractual issues will give you far better insight into the financial relationship that you have with your PBM partner.

Currently, we are actively providing auditing services for over 30 managed care plans across the United States, representing more than 40 million collective lives.

Medicare Part D Compliance & Mock Audit Support Clinical Guidance Specialty Pharmacy Sales and Marketing Support for Commercial Health Plans

Solid Benefit Guidance has the expertise you need and can equip and energize your sales force to get results!  Whether your focus is on:

  • Bringing the most competitive PMPM Rx cost to market for your fully insured business
  • Attaining new Rx growth with self-funded accounts
  • Educating your sales team to grow your pharmacy business
  • Looking for ways to maximize margins
  • Reducing pharmacy carve outs of existing or new accounts
  • Looking to carve back in groups you’ve lost
  • Creatively packaging your offers on par with the PBMs

Solid Benefit Guidance can help you with:

Customizable Pharmacy/PBM Training

Our highly effective training program has proven results and our approach is not only customizable but often qualifies for Continuing Education Credits.

Sales and Account Management teams are often tasked with representing numerous products to their clients (Medical/Dental/Life Insurance/FSAs and Pharmacy Programs). All too often the complexity of Pharmacy programs, results in clients carving pharmacy out of the Health Plan.

We can help you manage your pharmacy plan—we have trained thousands of Health Plan staff from sales/account management, pharmacists, underwriters, actuaries, proposal writers and medical directors to support your pharmacy program.  Our experience has proven that when you bring cross-functional teams together, you can yield favorable results.

Aside from training internal staff, we can develop training programs for your external channel partners (brokers/agents/consultants).

Tailor-Made Financial Model that will Improve Your Underwriting

As pharmacy pricing is opaque and often misconstrued in the evaluation process we will work with you to:

  • Develop a customizable financial model to assist with underwriting
  • Explore alternative pricing models, instead of the typical “one-size-fits-all” approach
  • Develop business terms and legal templates
  • Help you convey this language effectively and positively in proposals

Collaborative Pharmacy Support

Given the complexity of the PBM industry, Solid Benefit Guidance can work with your Pharmacy, Sales/Account Management, Marketing and Underwriting teams to become an extension of your organization.

Through a collaborative approach and a dedicated resource that gets to know the inner workings of your plan, we will work seamlessly and efficiently with your team to best position your proposals/renewals and client reviews to the market (clients/brokers and consultants).

Exchange and ACO Program Development

Solid Benefit Guidance knows how to successfully develop programs focused on driving the lowest net cost while balancing access and quality.

No PBM consulting firm is better equipped to assist an Exchange or ACO program. Our team is comprised of former Health Plan and PBM Underwriters and Clinicians who fully understand how to operate under a fully insured risk arrangement.

Today, our firm has worked successfully with a number of ACOs and Exchange plans to help negotiate, design and monitor PBM programs.

PBM Benchmarking and Strategy Development

We offer a highly customizable benchmarking service that will get to the root of the areas you are trying to assess.

This can be for financial, service, clinical or overall performance benchmarking to see how competitive you are (or can be) in your respective markets including an analysis of:

  • Network rates
  • Fees
  • Overall formulary rebate yields
  • Clinical performance (approval/denial and adherence)
  • Operational performance

Our Benchmarking Service is highly customizable to get to the root of the areas you are trying to assess.

With over 40 million Americans represented and an active consulting practice, we have one of the largest PBM databases in the United States. We are constantly working on new engagements across the managed care sector giving us real-time, relevant insights. The access to this robust/current data set and experience will prove to be invaluable when benchmarking your program.

Solid Benefit Guidance has been involved in over 20 pharmacy program re-designs based on Strategy Development engagements. Some examples of areas we will provide strategic guidance on include the decision to insource/outsource some or all elements of a pharmacy program including:

  • Claims Administration
  • Network
  • MAC
  • P&T
  • Clinical Programs
  • Rebate Contracting and Administration
  • Specialty (including the development of an in-house/Captive Specialty program)
  • Medical Specialty
Government Entities

Solid Benefit Guidance provides PBM consulting services for Government entities, including the Federal Government. We are experienced with fulfilling the Federal Office of Personnel Management (OPM) requirements, including Actual Acquisition Cost (AAC) models and transparency obligations.   

Our experience enables our firm to effectively manage PBM procurements in the Government arena, as well as serving as a validating consultant throughout this process.  We are also experienced in providing Specialty Medication Strategy and Formulary and Utilization Program Management Consulting Services for Government Entities.

If you missed or want to replay the ACAP Medical Benefit Medication Management Webinar?
Watch it on-demand right here

MBMM

 
Did you miss the Managed Care Pharmacy: What’s Coming in 2017? Webinar?
Watch it on-demand right here

Managed Care 2017

 

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