Partners Needed

March 26, 2015
|In Part D
|By GHG Advisors

I calculated the total amount of civil monetary penalties (CMPs) levied by the Centers for Medicare & Medicaid Services (CMS) last year on Medicare Advantage and Part D plans, and it’s a big number: $4,925,150. There were also five suspensions in 2014.

Now more than ever, plan sponsors need to assess their Pharmacy Benefit Manager (PBM) relationship to ensure that both parties are working in partnership to not only be successful as a business but to be CMS compliant. What is your PBM’s priority? Is your account management team responsive? Is your issues log so long that you’ve given up even trying to get resolution on the old items? Are you utilizing all of their existing reporting to consistently oversee and monitor the delegated functions they perform on your behalf?

There is no perfect PBM just as there is no perfect health plan. In our experience, it is a much less onerous process to make your current PBM relationship work than to go through a Request for Proposal (RFP) and implementation project which sucks up about six months of plan resources. Finding a new PBM should be your course of action only if you have exhausted all efforts to work with your current PBM partner.
Assess this list of successful PBM partnership tenets:

  • Detailed and specific PBM contract with clear definitions of the services to be provided.
  • Service level agreements (SLAs) for delegated function compliance.
  • Detailed and exhaustive oversight and monitoring plan for all delegated functions.
  • Frequent and productive account management interactions.
  • Transparent and full disclosure of all PBM-identified deficiencies which affect the plan sponsor.
  • Quick resolution of identified issues or agreed-upon timelines for issue resolution.
  • No CMS outlier communications due to PBM operational deficiencies.

Now is the time of year when health plans are planning for formulary submissions and working on their bids. Make sure you have the right PBM partner for a successful 2016. We can help! Contact us for more information.

Resources

The rapid changes to Part D regulations make the tracking and implementation of these CMS requirements exceptionally difficult — to say nothing of actually managing to them. Our Part D services are designed with your staff in mind, ensuring that with a mix of counsel and DIY tools your staff will have access to actionable information — faster. Contact us today to learn more >>

Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay’s analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!