Products & Services

Prior Authorizations & Pre-Certification Reviews

Pro Pharma can review Specialty medications daily or on an “as needed” basis for Prior Authorization. Evaluations can also be an in-depth chart review for benefit approved indications and support for therapy for extraordinary circumstances

Benefit & Formulary Design

Whether you have questions on particular drugs, require assistance on your P&T (Pharmacy and Therapeutics) Committee, or want help creating and maintaining your formulary – Pro Pharma has the knowledge and experience you need.

Managed Care & Pharmacy Expertise

We have been in Managed Care for many years and worked with a wide variety of Health Plans, Municipalities, Self-Insured Companies, and more. Pro Pharma customizes our approach for each client’s needs.

PBM Oversight & Monitoring

Pro Pharma reviews the pharmacy and medical data and can add focus to issues and concerns – giving recommendations as needed

Customized Maximum Allowable Cost List (MAC List)

Pro Pharma’s Custom MAC List is transparent, updated frequently, accessible to all – and the savings go to the Payer and Patients. The MAC List sets generic pricing to be normative (cost plus) for both Plans and Pharmacies.

JCode Calculator™ (Injectable Claims Pricing Tool)

JCode Calculator™ is a web-based resource to find prices, approved diagnoses, dosage limits, approved companion genomic testing, and much more! Search by HCPCS, NDC, or drug name quickly & easily.

Pharmacy Claims (Standard & Specialty Medications)

We call these Invoice Screens™ or current audit/analysis. Review of biweekly PBM pharmacy invoices for pre-adjudication claims can save you 7-11% in overall drug spend. Coupled with claims review, these screens can also focus on the providers, physicians and pharmacies responsible for rejected claims that did not meet contract requirements.

Integrating Pharmacy Claims & Medical Encounter Claims Retrospective

Pro Pharma analyzes pharmacy and medical encounter claims – identifying outliers and testing for cost, diagnosis, dose, utilization and clinical reviews. The outcomes include identifying claims that were paid for unapproved uses and paying specialty medication claims at a more favorable rate.

State & Federal Compliance

Pro Pharma performs State Compliance Audits for Health Plan Pharmacy Programs. The compliance audits reference applicable state regulatory code criteria. Both the Plan and the PBM are issued requests for documentation to support code compliance, delegation to the PBM, and summary bulleted information to help guide the audit.

Fraud, Waste, & Abuse (FWA)

At Pro Pharma, we have strategies to identify the offenders (Fraud) and prevent Abuse and Waste – going beyond their PBM’s approach

Forecasting & Predictions

Our program is unique in that we Combine integrated data sets of pharmacy, medical, laboratory, eligibility, Workers' Compensation loss runs, etc. We use Artificial Intelligence (AI) data sets across multiple data formats using Pharmacy Benefit Management (PBM), Third Party Administrators (TPAs) and health plan data sets collected for over 20 years.

Management Reporting Central

A self-serve analytics tool with selections by client type, organizational role, report name, report category, or search function. Executives, Medical Directors, Pharmacy Directors, and various client businesses can find the financial reports that are of greatest interest to them.