Navigate the complexities of government programs with confidence

Emerging market pressures are allowing PBMs to strategize new market ventures that align with the shifting populations of current and future members. Catering lines of business to new segments of the market can help increase ROI, alleviate risk, and strengthen customer retention. Diversifying capabilities is a potential outward-looking model for those willing to take on greater risk and capital investment, while inwardly strengthening current operations allows for leveraging market position through internal development and strategic collaborations for sustainable growth.
States have gained power through the ACA and have the potential to implement regulations that impact the operations of pharmaceutical companies and PBMs. Increasing influence at the state-level will further pressure PBMs to modify their business strategies to comply with legislative regulations. Advocacy among PBM leaders is crucial for opening up lines of communication with the state to improve the policies of health reform which could greatly affect the structures of formularies and regulate use of generic products and specialty pharmaceuticals.
PBM management is especially critical given CMS’ focus on drug benefit-related issues, such as prescription drug event reporting and transition fills. Our team performs in-depth compliance assessments to evaluate PBM performance as a delegated entity.  We’ll audit your team’s efforts to ensure that your PBM is accurately adjudicating claims on your client’s behalf and reporting accurately to CMS.  We’ll evaluate the efficacy of your MTM programs and much more.