Pharmacy Benefit Manager Review Services

Health Solutions

October 15, 2015

Health plans that offer Medicare Part D benefits often utilize Pharmacy Benefit Managers (PBMs) to administer various functions related to their Part D drug programs. The relationship between health plans and their delegated PBMs has been one of the major focus areas of the Centers for Medicare and Medicaid Services (CMS), as well as the Office of the Inspector General (OIG). Consequently, health plans have to be prepared to withstand this scrutiny by demonstrating proper oversight and audit of their PBMs.

The accumulating cost of noncompliance and inefficiency caused by a health plan’s PBM arrangement is certainly something that health plans who utilize PBMs must be aware of and take preventative measures against. Since most health plans are expected to have robust oversight of their PBM’s operations, risks to the financial, operational, and compliance standing of your health plan are ones that you cannot afford to take. FTI Consulting can assist health plans with determining whether your PBM is meeting regulatory and contractual requirements by offering a comprehensive suite of PBM review services to best suit your health plan’s particular needs.

FTI Consulting can tailor a review program with some or all of the following review services:

Formulary Administration
CMS has made the design, approval, and ongoing administration of Part D plan benefits and formularies a top compliance concern by including protocols for it in Compliance Program Effectiveness (CPE) reviews. FTI Consulting can help by measuring the extent to which the PBM has systems, policies, procedures, and processes in place to support their Part D plans’ CMS approved formulary files in the following areas:

  • Pharmacy and therapeutics committee documentation
  • System edits around use of Prior Authorization, Step Therapy Quantity Limits and other Drug Utilization Management edits
  • Compliance with CMS’ transition fill and associated notification requirements
  • Compliance with coverage determination, appeals, and grievance requirements
  • Testing of rejected and paid claims and case files to determine compliance with “protected class” and other drug types when applying claim system edits and controls

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