Pharmacy Benefit Management (PBM) Consulting

Clarity for better coverage and accessibility

The pharmacy benefit is one of the larger and more complicated features of any healthcare benefits package. It can be a challenge to stay informed about issues that affect your plan, making it all the more difficult to ensure your pharmacy benefit is delivering the most value to your organization and, most importantly, your employees.

The Gallagher’s Pharmacy Benefit Management (PBM) Consulting team is here to help. We leverage our real-world expertise and clinical insights to keep you up to date on issues that may impact your prescription drug plan. By assessing your current PBM contract, we partner with you to tightly design your next one, along with providing ongoing consulting focused on audits, managing costs and increasing plan satisfaction. And we don’t stop there. We conduct ongoing proactive strategic consulting including utilization studies, contract reviews and a deep dive into understanding the specialty drug pipeline, so you are constantly improving your programs.

The result? An organization powered by a healthy and engaged workforce, with potentially lower costs for you and your employees and a contract that is optimized for a constantly changing environment.

Pharmacy benefit programs are increasingly difficult to manage due to industry changes and skyrocketing drug prices. These circumstances affect your ability to negotiate lower costs for prescription drugs and manage drug utilization, which is becoming an increasingly higher percentage of overall healthcare spend, representing nearly 30% of total healthcare costs.

Cutting costs without reducing quality

Gallagher’s Pharmacy Benefit Management (PBM) Consulting team has cracked the code for identifying cost savings through savvy contract negotiations and precise auditing. We can help you better manage your prescription drug plans by utilizing a number of different tactics, tailored to the unique needs of your organization.

A strong contract that’s built to last

Your pharmacy benefit is only as good as your contract. When you partner with Gallagher, you have the power of first-hand knowledge of the pharmacy business model, which allows for unparalleled evaluation of pharmacy contracts. Together we’ll evaluate your options to uncover the best possible deal with fair, flexible and auditable contractual terms, without compromising on employee satisfaction and quality of care.

Knowledge is power

By partnering with Gallagher you will be able to guarantee that your pharmacy benefit is meeting contract obligations and paying claims accurately. Our plan financial reporting services provide a summary of your plan cost and analyze how and where those costs are occurring. This data drives further optimization of your pharmacy benefit – helping your plan deliver healthy performance and a healthy, engaged workforce.

The Gallagher Pharmacy Alliance: self-funded for more control

To help our clients under 3K lives gain better pricing and servicing options, Gallagher has developed a pharmacy coalition. The Gallagher Pharmacy Alliance is designed to specifically to provide smaller employers with better pricing and services than they would be able to access on their own. This is a good option for:

• self-funded
• quick RFP turnaround time
• highly focused on price
• interested in working with one of the larger PBMs but can’t do so based on their size
• no budget to complete a pharmacy RFP

The Gallagher Difference

The problem.

A large, self-insured benefit trust asked us to assess the quality of services provided by a national PBM and their specialty pharmacy for members who were receiving high cost medications for complex medical conditions. To understand the costs, we had to review a high cost claimant who received multiple medications (Firazyr, Cinryze, and Berinert) for the treatment/prevention of hereditary angioedema (HAE).

Our approach.

We conducted detailed case evaluations of the PBM’s and specialty pharmacy’s records. These records documented the clinical services provided to patients who had received specialty medications. It also shared the evaluation of routine follow-ups for medication refill coordination, routine screening and assessment by a pharmacist or healthcare professional of medication-related problems, clinical interventions, and care coordination.

The result.

We were able to find several ways to improve service and keep costs the same. The PBM and their specialty pharmacy took the several steps to enhance their clinical support services and care coordination efforts based on our findings:

• Enlisted an external physician expert to perform a case review and provide recommendations.
• Established a relationship between the PBM’s Medical Director and prescriber to provide peer-to-peer review of the patient’s case. The prescriber agreed to modify therapy.
• Claims surveillance showed a 25% drop in utilization of the patient’s HAE medications in the first three months following therapy modification, for annualized savings of up to $500,000.
• Prompted the PBM to modify its prior authorization criteria of high cost drugs to include:
  • Discontinuing routine lifetime authorization periods, in consideration of a maximum authorization periods of twelve months.
  • Placing quantity limits at average doses that will trigger a detailed case review, including review of medical records, and/or physician peer-to-peer review.
  • Providing additional triggers that will prompt PBM and specialty pharmacy staff to perform robust clinical reviews for drug appropriateness, proactive follow-up with prescriber, and enlisting expert consultation (e.g., medical director, external specialist expert).