Rebate Oversite and Analysis
PRO PHARMA has been active in audit and analyses of Rebates for the past twelve (12) years. Over the last few years PRO PHARMA has performed stand alone Rebate audits of ExpressScripts, Inc. (ESI), AdvancePCS, Caremark, Medco, National Medical Health Card, PharmaCare, etc. However, more commonly, Rebate audits are included in paid claims audits. Our experience includes analyses of 100% of rebatable claims experience, analysis of Rebate optimization opportunities, evaluation and re-negotiation of Rebate contracts, modeling of net cost vs. Rebate optimization scenarios (including indifference analysis), and simulation of benefit design scenarios to achieve lowest net cost.
PROCESS FOR CONDUCTING A REBATE AUDIT & DELIVERABLES:
There are several components of Rebate audits and analyses. Clients determine their interest or need for each of these audits. However, prior to all Rebate audits, current PBM and manufacturer contracts (if applicable, e.g., Rebate percent guarantees, or ERISA claim expense validation) are evaluated with the plan sponsor (usually onsite). A determination for contract support of Rebate recovery is made prior to the audit to ensure appropriate expectations for recovery.
This requires review/analysis of a separate database from the pharmacy paid claims dataset.
- Baseline Audit of "Rebateable" Claims
- PBM / Manufacturer Contract Review (where applicable)
- Net Cost vs. Rebate Optimization Modeling
- Benefit Design Scenarios vs. Impact on Rebate/Net Cost Optimization
For more information about these services or applicable rates
in your service area,
please contact Carol Stern @ 818-701-5438 or carol.stern@propharmaconsultants.com
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