A community-based health plan located in the Southeast with approximately 33,000 Medicare and Commercial lives was searching for an updated and more competitive contract with their current PBM. After completion of the third year of their contract with the PBM and not having exercised their right to a market check after year two, the contract was no longer competitive compared to what was being achieved in the current marketplace.
The health plan retained PillarRx to perform a mid-contract market check. Based on the existing scope of the health plan’s contract language, PillarRx utilized its proprietary database to evaluate the pricing and contract terms of clients similar in size, scope, and demographics to the health plan.
PillarRx collaborated with the health plan to understand their unique plan needs and requirements. After completing that exercise, PillarRx was well-positioned to recommend optimal contract audit and reconciliation methodology language as well as competitive pricing opportunities. This market check resulted in $9 million (12%) savings over the client’s remaining contract term.
The health plan continues to utilize PillarRx’s consulting guidance and auditing practice to keep its pharmacy benefit contract performance transparent and competitive.