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Twelve PBM Contracting Pitfalls ... and Ways to Avoid Them
Josh Golden, Senior Vice President Solid Benefit Guidance
Helen Sherman, Pharm.D., R.Ph., Vice President Solid Benefit Guidance
Thursday, June 30, 2016
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About the SpeakersJOSH GOLDEN is an area senior vice president at Solid Benefit Guidance (a division of Arthur J. Gallagher), where he is responsible for the successful delivery of a wide range of pharmacy consulting solutions to Fortune 500 employers, government entities, labor unions, and other benefit plan sponsors. He has over 17 years of experience as a strategic consultant within the health care industry, and brings to bear a keen understanding of the entire pharmacy benefits supply chain to help his clients optimize financial and health care outcomes for the populations that they cover. Josh is recognized as a thought leader in the pharmacy benefits arena, and is frequently called upon for speaking engagements and media inquiries at a national level. He has extensive expertise in the areas of vendor procurement, contract negotiation, benchmarking, audit and plan design consultation. Before joining Solid Benefit Guidance in 2016, Josh was the practice leader of the Employer Consulting Segment of Pharmaceutical Strategies Group, LLC. Prior to that role, Josh served as a senior pharmacy consultant with Aon Hewitt. He has also served as a pharmacy specialist consultant with Mercer Human Resource Consulting and a benefits analyst with Buck Consultants. His clients have included some of the largest and most complex employers in the country. Josh has a Bachelor of Science degree in Industrial and Labor Relations from Cornell University. Contact Josh at email@example.com.
HELEN SHERMAN, Pharm.D., R.Ph., is vice president at Solid Benefit Guidance, where her lifelong commitment to advancing the best use of medications supports payers, consumers and health care professionals with informed, value-based decisions. She is an advocate of health care transparency and value and focuses on using solid scientific evidence as a foundation for health care decisions. She is dedicated to helping clients develop effective solutions in a dynamic and evolving health care marketplace. Helen has comprehensive leadership expertise in pharmacy benefit management, including business development, market evaluation, clinical services, rebate management, sales, account management, operations, claims processing, customer service, Medicare Part D, Medicaid, regulatory requirements and vendor/system transitions. Helen spent 15 years in the health plan/pharmacy benefit industry, including as vice president for business development and chief pharmacy officer for RegenceRx (a health plan-owned PBM), where her leadership supported medication-purchasing decisions for 10 million members nationwide with an annual drug spend of $1 billion. She is an internationally recognized speaker and sits on several industry boards, including the advisory board of Drug Benefit News. Helen graduated from Oregon State University with a Bachelor of Science degree in Pharmacy and has a Pharm.D degree from Purdue University. Contact Helen at firstname.lastname@example.org.
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HEALTH PLAN WEEK is the nations #1 source of timely, objective business, financial and regulatory news of the health insurance industry. Published since 1991, the 8-page weekly features valuable insights and strategies for health plan managers and others who must monitor the activities and performance of health insurers. Coverage includes new benefit designs and underwriting practices, new products and marketing strategies, mergers and alliances, financial performance and results, Medicare and Medicaid opportunities, disease management, and the flood of reform-driven regulatory initiatives including medical loss ratios, exchanges, ACOs and myriad benefit design changes that are mandated.
SPECIALTY PHARMACY NEWS is a monthly newsletter packed with 12 pages of business news and management strategies for containing costs and improving outcomes related to high-cost specialty products. Designed for health plans, specialty pharmacies, pharma companies, providers and employers, the hard-hitting newsletter contains valuable insights into benefit design tactics, the emerging biosimilars market, specialty markets for certain conditions, formulary decisions, merger and acquisition activity, payer-provider partnerships, patient adherence strategies, and new products.
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Webinar MaterialsTwelve PBM Contracting Pitfallsand Ways to Avoid Them..........page 1
Josh Golden, Area Senior Vice President, and Helen Sherman, Pharm.D., R.Ph., Vice President, Solid Benefit Guidance
Selected Articles From AIS Publications..page 18
Webinar OutlinePart 1: Josh Golden and Helen Sherman, Solid Benefit Guidance
Overview of PBM Contracting and Revenue Model
Vague Brand/Generic Definitions
Price Modification Rights
Nuances of Transparency
Limited Termination Rights
Market Check Provisions
Audit Right Considerations
Hidden Fees & Charges
ZBD Priding Exclusions
Specialty Drug Nuances
Weak Service Performance Guarantees
Part 2: Questions and Answers
Twelve PBM Contracting Pitfalls And Ways to Avoid Them
The information contained herein is compiled by Solid Benefit Guidance from a variety of sources, and is provided for educational purposes only. This information is not to be distributed further without the permission of Solid Benefit Guidance.
Presented by: Josh Golden Helen Sherman, PharmD. firstname.lastname@example.org email@example.com 404-862-3605 201-571-3840 Solid Benefit Guidance Solid Benefit Guidance
June 30, 2016 An AIS Webinar
PBM Underwriting & Contracting
The PBM (Pharmacy Benefit Management) bidding and pricing process is extremely complex, and often opaque.
Like any high volume business, the fine print is where the money is made.
Subtle manipulation of definitions can have significant downstream financial impact.
There is constant movement within the industry, allowing vendors to manipulate margin over time.
Specialty pricing is playing an increasingly important role in total cost outcomes.
Business Transparency is used (and misused) widely in the industry, with mixed success.
There tends to be a lack of pull through negotiated items do not always end up in the contract draft.