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Pharmacy Benefit Management

A large segment of our business is focused on pharmacy benefit management (PBM) companies and assisting you with compliance, operations and interim staffing solutions. We have extensive experience in the PBM world, both on the clinical and operational side, with many operations experts and both founders of BluePeak being from the PBM industry. BluePeak understands the pressures of having many different health plans wanting different things from the PBM, as well as CMS actions that all hit at once, like the transition audits, and how hard that is to manage.


BluePeak staff has worked on both sides of the CMS world- as PBM business owners and CMS auditors and regulators. This gives BluePeak the edge of being able to support PBMs, understanding the business challenges that you face, as well as how CMS will audit you and your customers and their processes.  This allows for better preparation and maintenance of your compliance programs.

CMS Mock Audits

One of the most important activities that you can perform to get ready for CMS audits is practice universe pulls and mock CMS audits. BluePeak can assist you with preparation of universes, training of staff to present during the CMS audits and provide subject matter expertise in each of the CMS audit areas.  We employ former CMS auditors so that we can execute a mock audit just as CMS will perform the audit.  The report will contain information that will allow you to understand exactly where the issues lie and will give you actionable tasks that will allow you to remediate BEFORE CMS identifies the issues.

CMS Audit Support

During an actual CMS audit, BluePeak can assist with universe review and preparation, document and impact report preparations, coaching of staff and questions to ask or not ask CMS. We can be available onsite to support your teams. After the audit, BluePeak can assist with strategies for corrective actions, Corrective Action Plan (CAP) writing and review, and perform actual remediation work if needed. We can work with the business leads to design project plans, allocate resources and implement corrective actions. We can then perform a validation audit prior to the clean period to ensure the issues have been remediated.

Independent Auditor (IA) Validation

BluePeak can assist plans with the CMS IA validation process.  Our team will work with your team to develop a CMS-approved validation work plan, conduct the validation audit and provide the validation report to be shared with CMS.

Policy and Procedure Review and Writing

We can assist plans in drafting and reviewing policies and procedures—not only from the pure writing standpoint- but assuring that the operations of your organization are compliant and efficient leading to the saving of time and money.

Staff Training

Many of CMS’ findings are a result of inadequate training of staff in the various business areas. BluePeak can develop customized training programs to meet your needs and ‘train the trainers’ or deliver that training to your staff.  Developing training programs can be time and resource consuming, and BluePeak can take the burden off of your hands.

Healthcare Policy Analysis and Application

BluePeak understands the burden that daily HPMS memos can place on plans, especially small to midsize plans, that may not have the resources to monitor and interpret daily issues. BluePeak monitors, analyzes, and summarizes key Medicare legislation, regulations, and other CMS-issued guidance. We can provide training on policy-related issues for executives, directors, and staff and assess how policy developments impact specific business and operational areas of your business. We can them develop and implement practical and actionable steps so Medicare plan sponsor clients can proactively address policy-driven operational challenges and business opportunities head-on.

Interim Staffing

BluePeak can provide plan experienced compliance and operational professionals to assist your staff on when you may need some temporary extra support, or when you have had unexpected resignations.  Our team will also assist you with hiring the right people, with the right skill sets for your specific organization.

Oversight and Monitoring Programs

One of the major reasons plans get into trouble is that they do not have an effective, robust, compliant internal and/or downstream vendor monitoring program. BluePeak can develop or assist you in developing a customized program that is CMS compliant, while able to be operationalized with limited time and human resources from a plan perspective.


BluePeak staff has worked in the trenches at PBMs and health plans and understand the challenges that businesses face with limited resources and increasing CMS demands.  Our team can provide subject matter expertise across all operational areas of your business to enhance your business processes, fill in compliance gaps, provide interim staffing and train your staff to enhance their efficiency and effectiveness.

Process Remediation Support

BluePeak can provide subject matter expertise across all Medicare operational areas to enhance CMS compliance while improving operational efficiencies. Whether issues were identified in an audit, or internal monitoring, BluePeak can support appeals, grievances, coverage determinations, enrollment, payment, call center, medication therapy management, Drug Utilization Review (DUR), clinical programs, formulary, pharmacy networks or other operational areas in need of subject matter expertise and process remediation. In addition, BluePeak can advise on organizational restructuring across all operational areas.

Operational Gap Analysis

Operational gap analysis: BluePeak will provide an analysis of PBM operations to identify gaps where you may not be meeting CMS regulations and guidelines. We can do this across the PBM or in specific areas where you think there may be issues. We will then analyze the consistency across operational processes and written policies and procedures. BluePeak can assist plan with development of a database to demonstrate compliance with CMS regulations and guidelines or recommend online tools to support their businesses.

Vendor Oversight

CMS is turning their attention towards plan delegated vendors and how well that plans are overseeing and managing their vendors, paying particular attention to PBMs, print, clinical and enrollment vendors. BluePeak can review your vendor oversight programs, make suggestions for enhancements and assist with implementation of these new programs. BluePeak can also review your delegated vendors, and assist with operational assessments, vendor audits and ultimately new vendor RFPs if needed.

STAR Program Assistance

BluePeak can help you prioritize your resources to get the largest improvements for your dollar, as well as assist with project planning and strategies to enhance your Star ratings across all of your Part D measures. We can share best practices across the 4 and 5 Star plans that make them successful.

Operational Interim Staffing

BluePeak can provide plan experienced subject matter experts to assist your staff on operational issues when you may need some extra support, or when you have had unexpected resignations. Our team will also assist you with hiring the right people, with the right skill sets for your specific organization.

Staff Training

One of the most common issues within plans is lack of well-trained individuals that are performing critical daily operations. BluePeak will work with your staff and train them on specific operational processes or areas that may need some enhancement due to changes in guidance or staff turnover. In some cases, processes have changed on paper, but staff may not have caught up to the new requirements. BluePeak can help bridge those gaps.

Vendor RFP Support

Not happy with your current downstream vendors? BluePeak can make recommendations for cost-effective, compliant Medicare vendors and provide the RFP support if needed.


BluePeak has seasoned experts who are proficient at product strategy and development.  Whether it is assisting plans to go into new markets with new products, providing direction on starting an EGWP or PDP, or providing CMS benefit design and bid assistance, BluePeak can support new and existing plans to help grow their businesses.

CMS New Plan or Service Areas Expansion Applications

Interested in starting a new EGWP or PDP plan or doing a service area expansion? BluePeak staff has supported plans in completing many successful applications. We understand what is needed and what CMS’ expectations are with the new regulations and guidance.

New Plan Implementations

Are you new to the Medicare market? BluePeak has worked with many plans to implement a new product for an organization that is not familiar with Medicare. We will build a project plan, organize and hire internal staff, develop budgets, project manage the implementation, drive teams to completion of tasks and support CMS communications.

Product Strategy

Not sure if it is still a good time to get into the Medicare market? BluePeak can support plans with strategic and financial advice to make those tough decisions about what types of products, and when to enter the market.