Formulary and Rebate Management

Pharmacy benefit managers (PBMs) use formulary and pharmacy and therapeutics (P&T) processes to set guidelines for safe and appropriate medication use, control drug expenditures, and maximize rebates. With the increased changes in drug pipeline, stringent state and federal regulations, and continual growth in Medicare Part D and Health Insurance Marketplace (HIM) plans, health plans are seeking improved processes and efficiencies while ensuring member access to safe and effective therapies.

Additionally, formularies have evolved with increased complexities including more copay tiers, specialty tiers, utilization management edits, and drug exclusions—all in an effort to control spend. In a marketplace where drug coverage and pricing is constantly evolving, it is imperative that health plans have the solutions and processes in place to manage their formulary, stay compliant, and control cost without compromising the quality of care.

Argus formulary and P&T services provide a complete and flexible solution for both self-service and full-service customers. Our formulary management platform is integrated with our claim adjudication system. This automation allows for real time updates and management and meets Centers for Medicare & Medicaid Services (CMS), federal, and state compliance requirements. Additionally, our complete formulary and P&T services are bundled and included for customers who choose to utilize the Argus Formulary and Rebate Management services.

The pharmaceutical market has evolved in rebate contracting in an effort to drive product market share. Today, PBMs are negotiating rebates based on access, market share, and drug exclusions. We believe those are fundamental components of a plan formulary strategy; however, the approach does not address unit cost price increases. Argus Health offers a rebate strategy that can align with a health plan’s managed formulary and provide unit cost price protections across key drugs leading the trend. Our rebate solution will provide highly competitive rebates, formulary management, and net lowest cost with cumulative price protection.

We help mitigate the risk of increased drug costs by implementing a ceiling, or maximum allowable price, on the majority of brand name drugs that are available for rebates. If a drug’s inflation exceeds the threshold, the manufacturer refunds the difference between the increase and the threshold as a percent of wholesale acquisition cost (WAC). Additionally, our solution allows our customers to re-allocate their rebate resources to support other internal business and clinical priorities.