These full-disclosure models avoid the “bargain basement” administration fees of 10 cents to 1 dollar per claim, for example, that give non-fiduciary PBMs the green light to generate cash flows that are not readily apparent to the sponsor. Some of these PBMs are so brazen (or plan sponsors indifferent) that they are even offering $0 dispensing fees on top of $0 admin fees! The plan sponsor should be prepared for a greater upfront PBM administration fee, north of $4 per claim, in exchange for total disclosure of cash flows.
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The full-disclosure model PBM may not actively promote a specialty pharmacy or mail-order facility, because with no manipulation of AWP and a fair MAC for both the pharmacist and sponsor, the PBM has no economic advantage. The perception of many plan sponsors is that “AWP minus discount” and the “minimum rebate guarantee” are the two key components in evaluating the PBM proposal.
From my experience, the plan sponsor should take the time to investigate the cash flows to the PBM. It is a variable rarely considered in the evaluation of PBM proposals yet has a profound impact on net costs. The time invested in PBM selection can return significant cost savings on future pharmacy benefit costs.
Given the competition in the PBM industry and the potential for undisclosed cash flows, I believe that plan sponsors can use the information in this week’s tip to their advantage in selecting and monitoring their PBM’s performance.