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Pharmacy Benefit Actuarial Services

Services for Clients electing to seek the Federal Retiree Drug Subsidy (RDS)


Pharmacy Benefit Actuarial Services

If you offer pharmacy benefits to RETIRED employees or members who are Medicare eligible, you may be eligible to receive money from the government. As of January 1, 2006, the government provides a 28% drug subsidy for qualified retiree plans. To be eligible for the reimbursement, the Pharmacy Benefit Plan must be equal to or better than the Medicare Part D plan. An evaluation must be completed and signed by a certified actuary. An application will then need to be submitted to the RDS program 90 days prior to the effective date of the plan.

PBIRx® has the knowledge, experience, staff and efficiencies to help you understand this very complex legislation. PBIRx® has created a specific division within our company to handle this process, Pharmacy Benefit Actuarial Services (PBAS), to address the entire application process for our clients. They have actuaries on staff with the government required MAAA and FSA certification. Beyond the application, PBIRx® has created a model which aggregates member specific claim data comparing claims payable under Medicare Part D and excluded under Part B. PBIRx® has the ability to report costs to RDS on clients behalf, if requested. PBIRx® will provide you with a complimentary review of your pharmacy benefit plan information, including the estimated subsidy dollars, and a quote for services to assist in the preparation of the documents if you are eligible for the subsidy.

  • PBIRx® will:
    • Determine if your plan is eligible for the 28% subsidy.
    • Determine if a slight modification in your plan will provide you with the subsidy.
    • Develop and participate in a communication strategy for your Medicare eligible population.
    • Be responsible for communicating all of the employer paperwork deadlines required by the government, including creditable and non-creditable coverage documents for all Medicare eligible participants whether active or retired.
  • PBIRx® Services include:
    • Prepare actuarial equivalence test.
    • Provide assistance to Plan Sponsor in completing the subsidy application to enable Plan Sponsor to send all necessary information to CMS within required timeframes.
    • Prepare determination of "creditable or non-creditable coverage."
    • Assist in submission of enrollment information to CMS.
    • Submit aggregate drug cost data periodically to CMS. This is filtered through the Medicare Part D Formulary.
  • What is the process?
    • Call PBIRx® for a FREE consultation to determine if your plan may be eligible.
    • PBIRx® will provide a proposal with estimated costs and savings.
    • Upon a signed contract, PBIRx® will need the following information:
      1. File of Medicare eligible employees
      2. Current plan design
      3. Current claims specific to retirees
      4. Premiums paid by retirees
  • What will PBIRx® do?
    • Information Gathering: Acquire from Plan Sponsor: census, premiums, claims utilization, plan design, and other material as needed to assist in applying for the subsidy.
    • Actuarial Equivalency Analysis: Provide an Actuarial Attestation by an FSA certified actuary enrolled in the American Academy of Actuaries to determine if the value of the retiree prescription drug plan is actuarially equivalent to the program available through Medicare Part D. Should the Attestation Test fail, this analysis will inform the plan of where the benefit level needs to be in order to qualify for the subsidy. It can also determine if the estimated subsidy amount will offset the cost associated with the plan change.
    • Application Process: Provide assistance to Plan Sponsor in completing the subsidy application to enable Plan Sponsor to send all necessary information to CMS within required timeframes.
    • Eligibility Updates to CMS: Consult with Plan Sponsor to maintain and update RDS database containing the eligibility of each retired Medicare eligible individual. Eligibility updates can be provided by PBIRx® or Plan Sponsor.
    • Claim Data Submissions: Consult with Plan Sponsor to liaison with Plan Sponsor’s vendors to ensure that claims data is available and deliverable for cost reporting and reconciliation purposes. PBIRx® can provide cost reporting and final reconciliation if needed.
    • Eligibility Updates: Eligibility changes need to be verified by the group. PBIRx® will notify Plan Sponsor of when they will need to verify final covered retirees under the plan.
    • Reconciliation: Provide assistance to Plan Sponsor in completing the Reconciliation Process to enable Plan Sponsor to complete Final Reconciliation Steps and provide all necessary information to CMS within required timeframes.
  • What are the additional Services provided by PBIRx®?
    • Identify who holds the relevant claim and cost data and assess optimal cost reporting process.
    • Assess alternative options to the Retiree Drug Subsidy, including alternative Medicare Part D coverage options.
    • Consider renegotiating PBM agreements. Medicare Part D will eventually have a substantial effect on drug prices.
    • Handle all FAS106 & GAS45 reporting.

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