Pharmacy Benefit Manager Services
Pharmacy benefit managers (PBM) will continue to play an important role in bundled or more traditional managed care benefit structures. Participation in government programs, such as Medicare Part D, requires a different level of attention to administrative and system design issues vs. commercial programs.
The FTI Consulting team has worked with numerous PBMs to develop and implement the necessary compliance controls for their clients, as well as their own government contracts.
Our service offerings include:
- Formulary administration audits (includes review of drug utilization management program setup and ongoing administration)
- Claims and formulary rebate audits
- Clinical and administration program effectiveness reviews, including medication therapy management
- Detailed testing of formulary, clinical, pricing, and other system edit logic
- Strategic vendor alignment and RFP (request for proposal) process
- Post-merger integration and implementation
- Transition fill audits
- Rejected and paid pharmacy claims analysis
- Medicare Part B vs. Part D determinations process reviews
- Specialty and compound pharmacy claims adjudication and payment analysis
Senior Managing Director