AEGIS - Health Care Consulting, LLC

Our focus is on evaluation and auditing to reduce plan costs. We serve corporate clients, governmental agencies, labor organizations, unions, and managed care and insurance organizations with leading edge services.

Our evaluation and audit services include comprehensive audits of Pharmacy Benefit Managers (PBMs) for compliance with financial and plan terms and complicated audits of Medicare Part D programs.

We help clients recover prescription claim overpayments and renegotiate their PBM agreements, producing significant, long-term savings.

For Plan Sponsors (Employers, HMOs, Insurance Organizations, Labor Organizations)

Comprehensive claims audits of PBM performance for compliance with financial and plan terms
Identifying overpayments and errors with our proprietary auditing techniques and system
Performing onsite audits of retail, mail order, specialty and long term care pharmacies
Maximizing rebate payments
Identifying and reducing high cost drugs, such as specialty pharmacy
Audit accuracy and precision – auditing 100% of the claims data ensures no disagreement with the findings and subsequent recoveries from the PBM
Our audit financial recoveries are at least 2% of annual drug expenditures
Detailed analysis of your current PBM contract – identifying weaknesses that lead to 15% to 30% of cost increases
In-depth industry expertise: Gives you a negotiating edge with experts who have worked on the PBM side and can demystify pricing strategies and tactics.

For Medicare Part D Plan Sponsors

Comprehensive array of auditing services for compliance with all Medicare Part D guidelines
Scrutinizing your PBM vendor adherence to Centers for Medicare and Medicaid Services (CMS) requirements, including processing straddle claims, LICS indicators, and TrOOP accumulators
Verifying the accuracy of rebate payments from the PBM
Analyzing and verifying Fraud, Waste and Abuse reporting
Audits of Pharmacies, Physicians, Members and PBMs
Auditing Long Term Care, Specialty, and Home Infusion pharmacies
Our audit programs average a 3:1 return on investment and meet CMS requirements

Our most important role is to help our clients understand and navigate through the complex pharmacy labyrinth.

Prescription drug benefits have grown into a major expense burden. But how much cost is directly due to your Pharmacy Benefits Manager (PBM) practices?

PBMs often:

Hide their major sources of profit
Design benefit plans to maximize PBM profits
Charge group health plans more than they pay the pharmacy
Retain over 50% of drug manufacturer rebates
Overcharge for generics from their own mail order pharmacy
Have been subject to federal/state judgments and class action
& whistle-blower lawsuits

Is your PBM acting in your best interests – or theirs?

As a matter of due diligence, plan sponsors should inspect their PBM contract to validate their vendor’s performance. Like a second medical opinion, our independent and unbiased PBM Analysis & Audit is a prudent and cost-effective business practice.

Our analysis and audits often produce significant financial recoveries and an improved pharmacy management program.

Audit recoveries are at least 2% of annual drug expenditures.

Experience AEgis Experts. Experience Results.