PBM Contract Variance Analysis

IndustryManaged Care/ PBM
ProblemA PBM requested an independent investigation of a pharmacy network contract with a retail pharmacy chain. The contract required an in-depth review to assess a disputed variance between the paid claim rates and the contracted rates and the PBM’s total payments to the pharmacy.
PHSI SolutionPHSI examined the pharmacy network contract details to identify the agreed upon Generic Effective Rates (GER) and Brand Effective Rates (BER). PHSI applied the contracted rates to the processed claims over the contract life. A comprehensive analysis was performed and a sum of the price difference between the paid claims and contracted rates was summarized on a quarterly basis.
ResultsThe PBM client obtained an independent perspective of the contract terms and reprocessing of the claims history to calculate the GER and BER per the pharmacy network contract. The PBM better understood the factors and variations that contributed to the disputed rate with the contracted pharmacy chain. PHSI's independent analysis was used as a basis for resolving the dispute.