PBM Contract Variance Analysis
| Industry | Managed Care/ PBM |
| Problem | A 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 Solution | PHSI 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. |
| Results | The 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. |
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August 2023 Question of the Month
What steps do you take when learning about an electronic prescribing challenge?
Root cause analysis: 0%
Compendia review: 0%
Engage a partner: 0%
All of the above: 50%
None of the above: 50%
July 2023 Question of the Month
Does your organization have a strategy for Humira biosimilar launches?
Yes, well defined: 0%
We have a framework: 50%
Waiting for clarity: 0%
No: 0%
Unaware of need: 50%
June 2023 Question of the Month
How far in advance of NDA/BLA expected approval do (or should) manufacturers begin planning their compendia submission strategy?
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Initiation of Phase III Trials: 66%
6 months prior to approval: 33%
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No strategy: 0%
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