The Five Fundamentals of Pharmacy Contracting

Pharmacy benefits are confusing and ever-changing. To aid in the decision-making process we have developed a list of the “Five Fundamentals of Pharmacy Contracting.” When considering pharmacy benefits, all plan sponsors, even when carving-in, should be able to answer the following:

1) Do I have a contract specific to my pharmacy benefit? 

2) Does my contract clearly list out the discounts/fees/rebates that are applied to my claims utilization?

3) Does my contract clearly define under what circumstances those discounts/fees/rebates are

applied to my claims? In short, what are the contracts terms, conditions and assumptions?

4) Does my contract clearly state what detailed information I will have access to relative to my claims
     utilization and experience?

5) Does my contract contain audit rights that allow me to validate that my carrier or PBM is                 compliant with their financial obligations to our plan under the contract terms?