Formulary Management
& Pricing Validation

Formulary Management

SPS Health provides sustainable LTC pharmacy benefit designs, formulary management and real-time adjudication designed to improve clinical outcomes and drive post-acute savings for all LTC stakeholders.

Customized Formulary Design

SPS Health collaborates with pharmacy benefit administrators to develop formulary management protocols and pharmacy cost containment strategies.

Built for LTC pharmacies, our enhanced platform offers detailed reporting and actionable insights driving downstream savings to your customers and empowering you to compete in the challenging marketplace.

Tailored to LTC Pharmacies

Collaborating with pharmacy benefit administrators, SPS Health develops PBM formulary management protocols, enhances prescription benefit optimization, and implements pharmacy cost containment strategies. We ensure LTC partner facilities are positioned to provide medications, PBM formulary management services, and exceptional patient care.

SPS Health works with LTC pharmacies and staff to implement clinical formulary management protocols, streamline medication approvals, and facilitate provider approvals for medication therapy management. SPS Health’s skillfully designed clinical formulary management tools encourage medication compliance to improve outcomes and help lower costs by favorably placing the manufacturer’s drug relative to competing products.

Benefit Designs

SPS Health's skillfully designed clinical formulary management tools encourage medication compliance to improve outcomes and help lower costs, which includes:

Customizable
Plan Edits

National Drug Code (NDC) Exclusions
Maximum Allowable Cost (MAC) Management
Pricing Validation
Custom Formularies

Reconciliation and Reporting

Driven by data insights, SPS Health’s analytics and reporting enable post-acute pharmacy providers to validate contract compliance with downstream customers. This approach ensures transparency and helps in optimizing operations.

Real-Time Adjudication

The SPS Health platform offers a highly efficient real-time pharmacy adjudication feature that instantly empowers our customers with data-driven formulary management at the point of sale. We accomplish drug formulary compliance through cutting-edge functionality that allows the immediate rejection of high-cost and non-formulary products for third-party claims. Additionally, our adjudication system is uniquely designed for long-term care and is compatible with all pharmacy operating systems.

We firmly believe in the power of collaboration and work closely with pharmacy and facility groups to develop clinical formulary management solutions that effectively maximize cost-containment efforts. SPS Health is committed to delivering optimal results, and we strive to enhance the quality and effectiveness of the platform to benefit our valued partners further.

Platform Benefits

Compatible with all pharmacy operating systems.

Compliant with clinical formulary management and medication therapy management at the point of sale.

Detailed claim information for risk mitigation.

Optimizes clinical appropriateness with cost containment.

Efficient dispensing with high-cost alerts, refill-too-soon thresholds, package size edits, NDC exclusions, and custom rules.

Validates compliance with customers through detailed reporting.

Pricing Validation

SPS Health transforms Medicare Part A billing and elevates contract management setting a new standard of accuracy. Our powerful logic engine provides visibility into pricing errors and key spend drivers to uncover insights that empower facility- or contract-level decision-makers.

Purpose-built to handle the complexities of pharmacy and facility contracts, the platform:

Identifies billing errors

Offers transparent and validated pricing

Detailed claim information for risk mitigation

Provides customizable dashboards

Executes audit-ready confidence

How It Works

Contract Terms

Inputs Part A pharmacy contract terms into the proprietary logic engine.

Claims Ingestion

Pharmacy provides claims data for review.

Claims Evaluation

The logic engine utilizes necessary data sources to calculate the correct price.

Self-Service Analytics

Interactive reports and dashboards to generate plan insights.

Formulary Management & Pricing Validation