Formulary Compliance

Model N Formulary Compliance is a data validation and formulary auditing solution designed for pharmaceutical manufacturers. It automates formulary validations to help manufacturers verify that their drugs receive the contracted formulary positioning with payers and pharmacy benefit managers (PBMs), reduce overpayments, and support patient access to medications.

Formulary management presents ongoing challenges for pharma manufacturers: formularies change frequently, formulary data is often incomplete or outdated, and reconciling large prescription volumes against thousands of complex payer and PBM contracts through manual processes leads to delays, errors, and overpayments. Annual audits at individual companies have uncovered between $25 million and $75 million in overpayments attributable to non-compliant formularies.

Key Benefits

• Maximize market access: Formulary validations confirm that drugs receive the prioritized positioning specified in payer and PBM contracts.
• Reduce revenue leakage: Thorough audits of all products across plans within payment cycles reduce overpayments.
• Streamline operations: Real-time formulary data is accessible throughout the year, supporting more accurate and efficient validations.
• Improve customer satisfaction: Automated validations support precise, timely rebates and reduce the need for post-payment recovery.

Core Features and Capabilities

• Integrated formulary data: Provides collected and consistently stewarded formulary data covering most commercial and government plan formularies across all therapeutic areas.
• Rx-level formulary compliance: Compares contractual terms and conditions that drive rebates with published formulary data to determine compliance at the plan or individual prescription level.
• Reporting and visibility: Delivers insight into formulary compliance outcomes and trends to support account management and future contract negotiations.
• Elimination of manual validations: Removes the need for internal manual validation processes or reliance on third-party audits.

Workflow and Integration

• Formulary Compliance integrates with Model N Validata and Model N Payer Management to provide an end-to-end solution for managing payer contracts.
• The combined solution evaluates formulary compliance during rebate processing, improving calculation accuracy and preventing overpayments before they occur.
• It supports ending revenue leakage in payer contracting and rebating processes, ensuring both contract and formulary compliance.
• The solution is positioned to strengthen relationships with payers and PBMs by supporting accurate and timely rebate payments.

Formulary Compliance is part of Model N's Revenue Cloud for Pharma product suite, which also includes Payer Management, Validata, Government Pricing, Medicaid, and other life sciences-focused modules. The solution is delivered as a cloud-based platform.