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Business Cost Management for Payers
Business Cost Management
PQS’s cost management solutions help health plans optimize pharmacy spending. Our platform gives you clear visibility into prescribing trends, generic utilization, and adherence patterns, allowing you to easily identify what's driving your costs.

Boost formulary compliance and maximize value with value-based pharmacy programs that tie incentives to cost-effective care.
KEY FEATURES
Formulary Compliance Analytics
Tracks how often-prescribed medications align with the plan’s preferred formulary tiers. Identifies high-cost non-preferred fills and flags them for clinical review or member outreach. Supports automatic therapeutics interchange alerts so pharmacists can switch to formulary alternatives at the point of dispense.
Adherence-Based Savings Programs
Supports programs like synchronized refills and early refill planning. For chronic therapies, PQS identifies members who could safely move to 90-day supplies or mail-order (often cheaper), reducing gaps and avoiding complications that lead to high medical costs.
Value-Based Contract Performance
Monitors spend under pharmacy value-based contracts (e.g., outcomes-based rebates). Tracks metrics such as cost-per-member-per-month and total cost of care for program participants, enabling payers to refine contract terms.
Cost & Quality Analytics
Provides a unified dashboard of both cost drivers and quality measures. For instance, plans can drill into pharmacy spending by disease category to find opportunities where better medication management (a quality measure) also yields cost savings.
Aligning Care with Outcomes
Supporting Value-Based Care
Effective cost management is essential for value-based care. PQS's approach involves using data insights and a unified platform to reduce costs, close care gaps, and boost performance. By combining cost analytics with quality initiatives, plans that use PQS can make smarter decisions, like investing in a prevention program that generates significant savings and succeed in value-based reimbursement models.
Benefits
Lower Medical Loss Ratio
By surfacing which members are missing care (e.g., overdue A1C tests, immunizations, or refills), the analytics engine guides care management and pharmacy outreach. Plans can target interventions precisely, improving gap closure rates and boosting Star/HEDIS scores.
Better Contract Management
Close monitoring of pharmacy programs (like high-cost drug initiatives) allows proactive adjustments. For example, if a certain specialty drug’s spend is rising, plans can quickly intervene with utilization management or renegotiate pricing.
Improved Outcomes at Lower Cost
Aligning financial goals with patient care is the main focus. By ensuring medications are used effectively and efficiently, the plan reduces avoidable complications in line with value-based care objectives.
Value-Based Strategy Enablement
Detailed cost and utilization data empower payers to design smarter value-based pharmacy programs (e.g., shared-savings models with pharmacies). Analytics show which care gaps closure (e.g., better blood pressure control) leads to downstream savings, aligning incentives for both quality and efficiency.
Better patient outcomes. Better business results.

Adherence and 90-Day Programs

Improves PDC adherence; lowers per-unit dispensing costs; prevents costly gap-driven events.

Value-Based Contract Tracking

Monitors financial and clinical performance under VBC agreements; adjusts strategies in real time.

High-Cost Drug Management

Improves PDC adherence; lowers per-unit dispensing costs; prevents costly gap-driven events.

Formulary Compliance

Reduces spend on non-preferred drugs; ensures patients receive cost-effective alternatives.

Cost-of-Care Analytics

Uncovers hidden expense drivers; aligns pharmacy programs with broader medical cost reduction.

Tap into our expertise to improve patient and business outcomes

With 10+ years of quality measurement expertise and deep pharmacy knowledge, PQS provides best-practices to develop innovative quality strategies to support more effective interventions.
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