ACA Formulary Management and Analytics

Milliman FormularyIQ

By integrating medical and pharmacy ACA claims, rebates, premiums, and ACA risk adjustment revenue, Milliman FormularyIQ enables health plans to evaluate drug-level member profitability analysis, benchmark formulary coverage decisions, and align formularies with ACA formulary compliance requirements. FormularyIQ provides a comprehensive view for manufacturers to understand payer coverage decisions for ACA formularies.

Milliman FormularyIQ

THE CHALLENGE

Balancing formulary design, profitability, and compliance

Misaligned incentives across plans, pharmacy benefit managers (PBMs), and manufacturers complicate formulary management, particularly when ACA risk adjustment revenue is a critical driver of profitability. Limited visibility into drug-level performance makes it difficult to optimize ACA formulary strategy, manage anti-selection risk, and meet clinical, financial, and regulatory objectives.

THE SOLUTION

Data-driven ACA formulary strategy optimization

Milliman FormularyIQ brings together formulary management, profitability analysis, and healthcare compliance into a single analytics platform. Using integrated data and peer benchmarking, the solution evaluates exchange formulary design against state competitors, identifies outlier drugs, and quantifies risk-adjusted member profitability. This approach supports informed ACA formulary development strategy while enabling consistent alignment with regulatory benchmarks and market dynamics.

BENEFITS

Benefits of FormularyIQ

Optimize ACA formulary strategy

Evaluate drug coverage decisions using profitability analysis and ACA risk adjustment insights to support effective ACA formulary optimization.

Strengthen healthcare compliance

Assess formularies against ACA formulary compliance requirements and state benchmarks to

Improve competitive positioning

Benchmark exchange formulary design against peer plans to identify drug coverage outliers.

Align stakeholders with transparent analytics

Provide consistent, PBM-agnostic insights using comprehensive analytics that support collaboration across pharmacy, actuarial, and compliance teams.

FEATURES

Features of FormularyIQ

Analyze risk-adjusted profitability

Integrate medical and pharmacy claims, rebates, premiums, and ACA risk adjustment revenue to deliver detailed profitability analysis at the drug level.

Benchmark formulary coverage to market competitors

Compare formulary management decisions and utilization management controls against state competitors and a nationwide member profitability.

Evaluate ACA benchmark compliance alignment

Identify gaps between formulary coverage and ACA formulary benchmark compliance requirements.

Identify formulary outliers

Highlight drugs with coverage or utilization patterns that differ from market competitors to inform targeted ACA formulary strategy optimization.

Streamlined analytics dashboards

Use tailored dashboards to support pharma analytics needs across pharmacy, actuarial, compliance, and manufacturer teams.

Rich comprehensive dataset

Rely on a user-friendly dashboard powered with the most current, comprehensive ACA data available in the market, accounting for 100% of the ACA member utilization

Milliman FormularyIQ