Success Stories - Reily & Standard

Self-funded through a national Carrier, the Reily & Standard groups (Reily) drug spend is approximately $1 million annually. BancorpSouth Insurance's pharmacy benefits consultant, Ginger Campbell completed the initial evaluation and assessment of Reily's pharmacy benefit program in 2004. Working with the Carrier to collect 12 months of pharmacy claims data, Ginger then secured monthly electronic pharmacy data transfers. BancorpSouth was also provided with a copy of Reily's Carrier ASO Agreement and received a detailed description of their plan. The initial evaluation also included a clinical review on the overall health of the population, analysis of high utilizations areas, analysis of missed generic or lower cost brand opportunities and a retrospective claims audit.

During the above process, it was determined that there were no Reily specific pharmacy discount guarantees in any of the agreements between the Reily and the Carrier. This is all too often the case with pharmacy programs through a Carrier relationship. Ginger assisted in negotiating guaranteed discounts and drafted contract language that was signed by both parties that would allow BancorpSouth to make the Carrier accountable when audited.

A subsequent monthly repricing analysis uncovered that over several months a large number of claims were being processed at discounts that did not meet the guaranteed per claim discounts agreed to in the contract. After reviewing the claims, the Carrier agreed with the findings and credited the group $20,000 — the amount of the overcharge. The Carrier also volunteered to audit themselves on an additional 6 months of claims that resulted in another credit to the group of approximately $10,000.