Strategic Partnership &
Procurement Services
Insights
Three large vertically integrated PBMs account for 80% of total equivalent prescription claims – CVS Health (Caremark), Cigna (Evernorth, Express Scripts) and UnitedHealth (OptumRx). However, multiple other PBMs, health systems and pharmacy solutions offer customized, unique and customer-oriented services at competitive pricing. Further, there are novel partnerships evolving to deliver new care models that are disruptive to traditional insurance carriers.
We will guide you through options based on your strategic plan and then run the process to seek and implement fresh alternatives, taking that work off your plate. We always begin and end with your goals and objectives.
Our Solutions
Assess Current State and Build Desired Future
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Education on pharmacy landscape, trends and market​
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Analyze current data sets
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Opportunity assessment (clinical/cost/model)
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Plan design review
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Strategic planning and goal session
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Alternative model/vendor review
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Design custom plan
RFI/RFP Process and Vendor Selection
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Build and manage customized RFI/RFP process​
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Run finalist and best and final process supported by waterfall financial analysis
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Lead contracting phase with new vendor
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New vendor implementation
Ongoing Program Management
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Quarterly analytics, performance assessments and savings analysis​
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Annual strategic plan
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Clinical support
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Sales and account management support
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Data warehouse services
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Auditing of clinical services
Specialty and High Cost Medication Services
Insights
The median annual price of the 17 novel drugs the U.S. Food and Drug Administration (FDA) approved since July 2022 is $193,900. For full year 2022, the median was $222,003. 1
Twenty cell and gene therapies are projected to be approved by 2025 and more than 500 gene and cell therapies are in the development pipeline. Cell therapy prices differ depending on the indication and the type of product, but the average cost per treatment is $1 million, according to the ICER. 2 While some industry experts say these treatments could transform medicine by curing diseases, we know there is still no industry blueprint for supply and delivery, administration and evaluation, and paying for these complex, more personalized treatments.
Working with you and your broker, we will guide your decisions on what coverage, care and risk management solutions you need in your benefit program.
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1. Source: Reuters survey of companies that received FDA approval for a new drug in 2022.
2. Health Affairs, JANUARY 19, 2023 10.1377/forefront.20230117.110613
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Our Solutions
Only three percent of your members use specialty and high-cost medications but they represent up to 50% of your pharmacy spend or more in the case of gene and cell therapies. When these treatments are inadvertently wasted during distribution or administration, or used in appropriately the financial risk to you is extremely high. Here is how we help minimize your risk, one member at a time.
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Oversight / Management
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Monitor and manage high cost claimants
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Audit vendors to assure accountability
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Aggregate case data/report clinical and financial metrics
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Quarterly review of case performance/savings
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High-touch services
Navigate use to high-value providers for fulfillment and/or administration, promote use of lower cost alternatives, provide clinical specialist support to member and providers, track compliance to national guidelines and standards of care.
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Insights
Your employees and their families are everything to you. You want to optimize savings and value of your pharmacy program but that could lead to a change in member's experience and often they get put in the middle. We will take the transition work off of your plate with this concierge-level service.
Our Solutions
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This high-touch service is a change management vehicle that takes members and providers through any transition to assure that they do not go without medication and are experiencing optimal savings and value of the benefit. And the same goes for you.
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Modules:
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Transition to new vendor drug lists and utilization management programs
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Transitions to new pharmacies/providers
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Comprehensive medication management services post implementation
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