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Medicare Part D and Pharma

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Medicare Prescription Payment Program (M3P)

Beginning in 2025, the prescription drug law, known as the Inflation Reduction Act, requires all Medicare prescription drug plans (Medicare Part D plans) — including both standalone Medicare prescription drug plans and Medicare Advantage plans with prescription drug coverage — to offer enrollees the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments instead of all at once at the pharmacy, otherwise known as the Medicare Prescription Payment Program or M3P.

BluePeak can support the implementation of M3P at every stage of the process including Enrollment, Marketing, Billing, Claims Processing, Planning for questions and complaints, and Termination.

Part D

Medicare Part D claims are under more scrutiny than ever. Let BluePeak help you identify and remediate common audit findings such as unbreakable packages, Part B vs Part D determinations, transition, protected class drugs, and utilization management restrictions. Our testing approach supports your team from formulary analysis through paid and rejected claims analysis and monitoring. BluePeak also provides targeted testing for IRA provisions such as insulins and vaccines.

Prescription Drug Event Management

Let BluePeak Advisors Monitor, Manage and Maximize your PDE data with our PDE3 service. Our PDE experts will work with your team to validate the accuracy of your PDE records and CMS payments, while reducing your PDE rejection rate.

  • Audit PDE records for payment accuracy
  • Maintain audit logs and assist with corrections
  • Reconcile monthly CMS financial reports
  • Validate quarterly Coverage Gap Discount payments
  • Perform plan-specific PDE financial outputs
  • Collaborate to maximize PDE acceptance rate to optimize CMS payments
  • Mitigate future PDE rejections
  • Generate monthly PDE reports

GLP-1 Retrospective Reviews for Medicare Plans

BluePeak is assisting plans in developing their retrospective GLP-1 review processes.  BluePeak can also conduct the retrospective review on an initial or on-going basis.  Fraud waste and abuse trend reports from CMS have included GLP-1s as potential targets. GLP-1, or glucagon-like peptide-1, is a hormone that plays a crucial role in regulating blood sugar levels. Beyond its role in diabetes management, GLP-1 has also been found to be effective in promoting weight loss. Several medications that target GLP-1 receptors have been developed, offering a promising avenue for individuals struggling with obesity.

Pharmaceutical Analytics and Services

BluePeak provides strategy and services specific to pharmaceutical manufacturers’ needs. We are uniquely qualified to provide industry expertise to pharmaceutical manufacturers.

  • Knowledge in the health plan and employer client marketplace.
  • Knowledge and in-depth experience with CMS policy and ongoing industry challenges.
  • Experience delivering focused training sessions on the complex pharmacy benefits for public and private insurance on the complex Medicare benefit and program
  • Thought leaders in industry groups

Medication Therapy Management (MTM)

Targeting members for participation in your MTM program is required by CMS. BluePeak can assist with development of your MTM program eligibility, including drug and diagnosis information. We will review your eligibility and claims files to ensure proper identification of eligible members, disenrollment when appropriate, and confirm if your program implementation is compliant. Our subject matter experts are here to assist you with a best-in-class MTM program.

Capabilities to Support PBMs

Did you know BluePeak off­ers comprehensive Pharmacy Benefit Manager (PBM) operational and compliance services to help PBMs deliver to their government sponsored health plans?

BluePeak has several programs to support a PBM to ensure you are providing compliant services to support your Medicare clients.

  • Year-End Formulary and Benefit Testing
  • Claims Monitoring
  • Call Center Training
  • Mock CDAG and FA Audits
  • Operational Assessment
  • Prescription Drug Event (PDE) Process Review
  • Compliance Support

Formulary Management Strategies

BluePeak understands the importance of formulary management in driving clinical and financial outcomes. Our multi-disciplinary team can design and manage formulary solutions that align with your organization’s unique goals.

PBM Implementations/Transitions

BluePeak can assist with PBM implementations and transitions.  Our team will work both your team, your existing PBM, and your incoming PBM to ensure a successful go-live. BluePeak offers a wide array of implementation and transition support services to help ensure that a vendor transition is smooth and successful.

PBM RFP Development, Review, and Contracting

BluePeak offers Plans an industry-leading End-to-End PBM Procurement Process designed by former PBM Underwriters and Professionals. BluePeak’s procurement process is designed around optimizing the final PBM service agreement and leads to BETTER transparency & PBM Partnerships. Our partnerships with large, sophisticated clients has given us unrivaled experience in supporting efforts to
carve-in, carve-out and/or insource nearly every element of the PBM business model. Plans can select the complete end-to-end process or we can customize a project to support any phase along the way.

BluePeak is a leading national healthcare consultancy that focuses on government programs including Medicare Parts C and D, Medicaid, and Exchanges. We assist health plans, pharmacy benefit management (PBM) companies allied health companies and pharmaceutical manufacturers with regulatory, operational and compliance issues. BluePeak can analyze an organization’s processes and provide practical solutions, operational best practices and training to meet Medicare and other government program standards in all key areas.

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