Directors of benefits face the challenge of managing escalating pharmacy costs while ensuring optimal outcomes for plan members. Pharmacy Benefit Managers (PBMs) are increasingly leveraging data analytics to address this complex task. How pharmacy benefit managers leverage data analytics is a must-read Q&A. Let’s explore the role of data analytics in PBM operations, its benefits, challenges, and future potential.

Why Do PBMs Use Data Analytics?

PBMs use data analytics to balance cost savings with improved patient care. Analytics optimizes formulary design, identifies patients at risk of non-adherence, detects anomalies in claims data to combat fraud, and tailors wellness programs to member needs.

What Type of Data Do PBMs Collect?

PBMs collect prescription claims, clinical data, adherence metrics, drug pricing trends, and patient demographics. This comprehensive data pool supports targeted interventions and strategic decision-making.

Would a PBM Contact a Provider or Pharmacy About an Alternate Medication Regimen?

Yes, PBMs often collaborate with healthcare providers or pharmacies when analytics suggest that a patient could benefit from an alternative regimen. These interventions focus on optimizing clinical outcomes, reducing costs, or improving adherence, while maintaining respect for the provider-patient relationship.

How Do PBMs Address Patient Needs With the Data They Collect?

PBMs segment patient populations to deliver targeted interventions, predict health outcomes, and personalize support services. For example, analytics might help identify patients who could benefit from additional resources, such as mobile tools or nurse support lines.

How Do Data Analytics Help Enhance Patient Care?

Data analytics increases medication adherence through automated reminders and predictive models, streamlines care coordination by bridging gaps between stakeholders, and identifies cost-effective therapies to ensure access to affordable, clinically effective medications.

Challenges: Changing Regulations and HIPAA Compliance

Regulatory Issues

Evolving regulations may restrict access to critical data or impose additional compliance requirements, complicating analytics efforts.

HIPAA Compliance

HIPAA adds challenges like safeguarding sensitive data and navigating restrictions on sharing patient information. PBMs must ensure robust security measures and strict compliance to utilize analytics effectively.

The Future of PBM Data Analytics

The integration of Artificial Intelligence (AI) and machine learning will revolutionize PBM analytics by enabling:

• Real-Time Insights: AI-powered tools can process vast amounts of data instantly, delivering actionable insights faster than ever.
• Enhanced Predictive Modeling: Advanced algorithms will refine the ability to predict patient behavior and health outcomes.
• Personalized Care: AI will drive highly customized patient support programs based on individual data.

Conclusion

Data analytics is a cornerstone of modern PBM operations, driving cost control and improved patient outcomes. However, regulatory challenges and privacy concerns necessitate careful navigation. With advancements in AI, PBMs are poised to further enhance their analytics capabilities, offering even greater value to plan sponsors and members alike.

Proposed Legislation Targets Pharmacy Benefit Managers, Calls for Pharmacy Divestiture and other notes from around the interweb:

• Proposed legislation would require pharmaceutical benefit managers to divest of pharmacies. The bill, sponsored by U.S. Senators Elizabeth Warren, a Democrat, and Josh Hawley, a Republican, will force companies owning health insurers or pharmacy benefit managers to divest their businesses operating pharmacies within three years. Representatives Diana Harshbarger, a Republican, and Jake Auchincloss, a Democrat, are also supporting the bill, which will be introduced in the Congress. PBMs negotiate prescription drug prices between insurers, pharmacies and drugmakers, and directly reimburse pharmacies for prescription drugs included under their agreed terms. They have previously come under scrutiny for their influence over prescription drug prices. “PBMs have manipulated the market to enrich themselves — hiking up drug costs, cheating employers, and driving small pharmacies out of business. My new bipartisan bill will untangle these conflicts of interest by reining in these middlemen,” said Senator Warren.

• Mark Cuban: Buying prescription drugs is ‘just like buying lettuce‘. Mark Cuban is making his Cost Plus Drug Co. online pharmacy and discount card program a test of the proposition that the U.S. prescription drug market is just another market. When employers use traditional pharmacy benefit managers, they often have a hard time getting basic information about claims, the rebates the PBMs have negotiated and where the rebate value is flowing, Cuban added. Cuban argued that the prescription drug market and other health care markets can work like the market for fruits and vegetables if the suppliers provide enough information. “If you want an efficient market, you have to have pricing available for everybody to evaluate,” Cuban said.

• Antitrust Class Actions Against CVS, Other Pharmacy Benefit Managers Are Piling Up. Plaintiffs, independent pharmacies, claimed the defendants “have vertically integrated” with health care giants such as insurance companies, health care providers, private drug labelers and others. As a result, the complaints say, pharmacy benefits managers use anticompetitive methods to suppress reimbursements for discount card payments, which allegedly causes stand-alone pharmacies to suffer and even go out of business. “Each of the PBM Defendants is a wholly owned subsidiary of a healthcare conglomerate that also owns mail-order, specialty, and/or retail pharmacies, large health insurance companies, and other players in the market for prescription dispensing services,” the Philadelphia Association of Retail Druggists argued.

• PBM Contracting and Administration: What Are the Rules of the Road for Self-Insured Employers? Recently, PBMs have faced growing scrutiny, especially for their role in drug pricing and lack of transparency. Less attention has been given to the misuse of drug formularies—the foundation of drug benefits, listing medications covered by health insurance. While some argue formularies’ purpose has remained consistent over 30 years, others disagree. Initially, a pharmacy and therapeutics committee within a PBM, health plan, or other organization developed drug formularies. Clinicians and other experts on the committee determined the drug’s safety, efficacy, and unique clinical aspects. If the drug met their standards, they placed it on the formulary.

For years, Pharmacy Benefit Managers (PBMs) have controlled the narrative around prescription drug costs, operating behind a veil of secrecy. But self-insured employers, brokers, and consultants have the power to rewrite that story. Watch “Navigating PBM Profit Tactics” to uncover strategies for managing costs and driving transparency in pharmacy benefits.

During a recent webinar, Tyrone Squires, a visionary in pharmacy benefit management, shed light on the practices that drive up costs and provided actionable strategies to help organizations take control. If you’ve ever felt frustrated by rising pharmacy expenses or wondered where your dollars are truly going, this session is your road map to clarity and empowerment.

Unmasking PBM Profit Strategies

PBMs are masters of complexity, employing tactics that often go unnoticed until it’s too late. Here are a few common practices they use:

• Spread Pricing: PBMs charge employers more for drugs than they reimburse pharmacies, pocketing the difference.
• Rebate Retention: Instead of passing savings to employers, PBMs keep significant portions of manufacturer rebates.
• Hidden Fees: Contracts with vague language allow for fees that inflate overall costs.

But these tactics are not inevitable. By understanding how they work, you can uncover hidden revenue streams and redirect them toward meaningful healthcare investments.

Why Fiduciary PBMs Are Game-Changers

Imagine a PBM that works for you, not the other way around. That’s the promise of the fiduciary model—an approach built on transparency and aligned incentives. Fiduciary PBMs commit to acting in their clients’ best interests, offering:

• 100% rebate pass-through.
• Clear, simple contract terms.
• Fee structures that prioritize value over volume.

With a fiduciary PBM, you’re no longer at the mercy of opaque practices. You’re in control, making decisions that align with your organization’s goals and values.

Practical Steps to Reduce Pharmacy Costs

Empowerment starts with knowledge—and action. Tyrone Squires outlined specific strategies to take charge of pharmacy benefits:

1. Audit Your PBM Contracts: Shine a light on hidden fees and ambiguous terms.
2. Carve Out High-Cost Drugs: Shift specialty medications to more affordable alternatives.
3. Leverage Formulary Management: Create a drug list that balances cost savings with patient needs.

These steps aren’t just about cutting costs; they’re about reclaiming your organization’s right to transparency and fairness.

Oversight Is Key: How to Hold PBMs Accountable

Accountability isn’t a luxury—it’s a necessity. With the right oversight tools, you can ensure your PBM is delivering the value you deserve.

• Conduct Regular Audits: Verify claims, fees, and rebate arrangements.
• Set Clear Performance Metrics: Use KPIs to measure savings and member outcomes.
• Adopt Advanced Analytics: Leverage data to uncover inefficiencies and optimize programs.

Every audit, metric, and analysis brings you closer to a benefits program that works for your organization—not against it.

Believe in the Power of Transparency

Transparency is more than just a buzzword—it’s a movement. When you demand openness, you unlock a benefits plan that serves your team’s health and your organization’s bottom line.

This isn’t just about reducing costs; it’s about creating a system that prioritizes fairness and outcomes. By taking action, you set an example for others, inspiring a ripple effect of positive change in the industry.

Your Journey Starts Here

The path to better pharmacy benefits begins with a single step. Whether you’re a CFO, CHRO, or benefits consultant, now is the time to demand clarity, embrace accountability, and deliver meaningful results for your organization.

Are you ready to lead the change? Watch “Navigating PBM Profit Tactics” and discover actionable insights to manage costs and enhance transparency in pharmacy benefits. Connect with Tyrone Squires today to explore how a fiduciary PBM model can transform your approach to pharmacy benefits.

PBM Contracting and Administration: What Are the Rules of the Road for Self-Insured Employers and other notes from around the interweb:

• PBM Contracting and Administration: What Are the Rules of the Road for Self-Insured Employers? Recently, PBMs have faced growing scrutiny, especially for their role in drug pricing and lack of transparency. Less attention has been given to the misuse of drug formularies—the foundation of drug benefits, listing medications covered by health insurance. While some argue formularies’ purpose has remained consistent over 30 years, others disagree. Initially, a pharmacy and therapeutics committee within a PBM, health plan, or other organization developed drug formularies. Clinicians and other experts on the committee determined the drug’s safety, efficacy, and unique clinical aspects. If the drug met their standards, they placed it on the formulary.

• Effort Underway to Improve Standards for REMS Adjudication. Specialty pharmacists’ Risk Evaluation and Mitigation Strategy (REMS) for high-risk medications is often cumbersome, requiring manual entries and a lengthy, multi-stakeholder process to confirm the drug’s benefits outweigh its risks. Ensuring REMS compliance is sometimes so laborious that a patient does not receive a needed medication. That’s because the authorization to dispense the drug expires after frequent back-and-forth between a pharmacist and REMS administrator. Such delays often are due to nonstandard processes that add complexity and time to an already loaded interaction, the speakers said. “I’ve seen pharmacists in tears over what they have to do to adjudicate a REMS [medication],” said Justin Wilson, BS, the global risk management, and REMS technology lead at Syneos Health, in Morrisville, N.C.

• Legislators urge DOJ to investigate PBMs for potential role in opioid epidemic. Recent reports, including confidential files and information from CVS Caremark, Express Scripts and Optum Rx, suggest the three largest PBMs colluded and conspired to steer patients towards Oxycontin in exchange for $400 million,” the legislators wrote. The allegations stem from an October article in Barron’s that details the findings. The outlet reported that these three firms collected $400 million in rebates and fees from Purdue Pharma over a year ending in late 2017. Barron’s noted that the PBMs kept most rebates instead of passing savings to consumers. The letter also criticizes major PBMs for their ties to health insurers, group purchasing organizations, pharmacies, and other healthcare businesses. Vertical consolidation in healthcare has been a central concern for policymakers looking to reform the PBM industry.

• The Inflation Reduction Act’s implications for employer-sponsored health plans. The Inflation Reduction Act (IRA) aims to lower prescription drug costs and enhance Medicare benefits. While these changes benefit Medicare recipients, they raise concerns for employer-sponsored health plans that are not part of government price negotiations. These plans could see cost increases due to price shifts, with premiums rising for employers and employees alike. The primary concern is that non-Medicare participants will bear these higher costs as pharmaceutical companies and health care providers raise prices to offset lost revenue. Historically, Medicare’s cost reductions have led to higher prices for employer-sponsored plans. When Medicare sets lower prices for services under Parts A (hospital) and B (outpatient), providers often shift costs to those with private insurance to maintain profitability. This trend is expected to continue under the IRA.

Directors of Benefits and employee benefit brokers are under increasing pressure to deliver comprehensive, cost-effective strategies while maintaining exceptional outcomes for plan members. One of the most impactful ways to achieve this is by leveraging data from medical and pharmacy benefit claims. Data alignment is no longer optional—it’s essential for managing costs, optimizing plan performance, and meeting the needs of today’s self-insured employers. Directors of Benefits and employee benefit brokers must grasp how data is revolutionizing medical and pharmacy benefit decisions.

Why Data Alignment Is Crucial for Benefits Management

Medical and pharmacy claims data often exist in silos, creating blind spots in cost management and care strategies. For example, understanding the total impact of high-cost specialty drugs requires analyzing both medical (J-codes) and pharmacy benefits. Without alignment, it’s nearly impossible to identify patterns, optimize formulary decisions, or improve outcomes.

Aligned claims data allow benefits professionals to:

• Pinpoint Cost Drivers: See the complete picture of how certain drugs or conditions affect plan costs.
• Support Better Plan Design: Use integrated data to create benefits that balance cost control with member satisfaction.
• Deliver Strategic Insights: Provide employers with actionable recommendations based on real-world analytics.

Implementing a data-driven approach to benefits management begins with investing in technology that integrates data from medical and pharmacy claims into a unified platform. This step is foundational, as it enables a comprehensive view of costs, utilization, and outcomes. Once the technology is in place, the focus shifts to prioritizing transparency, ensuring that all stakeholders—whether payers, brokers, or plan sponsors—can access and understand the data driving decisions. Transparency builds trust and allows for more informed discussions about cost-saving strategies and plan performance.

Next, fostering collaboration between medical and pharmacy benefit teams is essential. By breaking down silos, these teams can work together to identify patterns, improve member outcomes, and align strategies. The process continues with the adoption of predictive analytics to anticipate trends and costs, enabling benefits professionals to recommend proactive interventions. For example, predicting the impact of high-cost specialty drugs allows brokers to guide employers toward cost-effective solutions before expenses spiral out of control.

Finally, all efforts must converge on a member-centric approach that focuses on improving employee health and satisfaction. By aligning benefits with the needs of plan members—such as medication adherence programs or personalized interventions—employers can achieve better outcomes while controlling costs. As a result, this integrated, step-by-step approach not only enhances decision-making but also positions brokers and benefits directors as indispensable partners in delivering value to self-insured employers.

What Results Can Directors of Benefits and Brokers Expect?

By aligning medical and pharmacy claims data, benefits teams can achieve:

• Cost Savings: Unified data uncovers inefficiencies and opportunities for savings, such as moving high-cost J-code drugs from medical to pharmacy benefits, where discounts and management are more robust.
• Better Employer Retention: Employers want results. Offering aligned, data-driven strategies positions brokers as indispensable partners in their success.
• Improved Outcomes: Benefit strategies rooted in data lead to healthier, more productive employees and fewer costly interventions.
• Stronger Reporting: Unified data simplifies the process of meeting reporting requirements while providing powerful insights to employers.

Why It Matters for Brokers and Benefits Directors

As the healthcare landscape evolves, self-insured employers expect more from their benefits professionals. By driving discussions around data alignment and sustainable strategies, you can position yourself as a forward-thinking leader who delivers measurable results. Data isn’t just a tool—it’s your competitive advantage. Use it to design benefits that control costs, improve outcomes, and meet the demands of the modern workforce.

The Inflation Reduction Act’s implications for employer-sponsored health plans and other notes from around the interweb:

• The Inflation Reduction Act’s implications for employer-sponsored health plans. The Inflation Reduction Act (IRA) aims to lower prescription drug costs and enhance Medicare benefits. While these changes benefit Medicare recipients, they raise concerns for employer-sponsored health plans that are not part of government price negotiations. These plans could see cost increases due to price shifts, with premiums rising for employers and employees alike. The primary concern is that non-Medicare participants will bear these higher costs as pharmaceutical companies and health care providers raise prices to offset lost revenue. Historically, Medicare’s cost reductions have led to higher prices for employer-sponsored plans. When Medicare sets lower prices for services under Parts A (hospital) and B (outpatient), providers often shift costs to those with private insurance to maintain profitability. This trend is expected to continue under the IRA.

• What to know about brand-name and generic drugs. When choosing medications, patients typically encounter brand-name and generic drugs. While both types are designed to treat medical conditions effectively, understanding their subtle differences can help you make more informed decisions regarding your health. One of the first noticeable distinctions between originator and generic drugs is their name. Generic medications are typically named after the drug’s active ingredient instead of the manufacturer’s brand. The cost and appearance of the medication are also key differentiators. Generic medications are typically 80-85% less expensive than the brand-name version, primarily because they undergo fewer development processes. Although the drugs have the same active ingredients, they do not have to include the same inactive ingredients. This means the medication can appear different in color, shape, or size.

• Pharmacies Accuse GoodRx of ‘Inviting Price-Fixing’ in Series of Antitrust Class Actions. The plaintiff pharmacies alleged that GoodRx, a prescription discount card aggregator, and four of the largest pharmacy benefit managers (PBMs) engaged in a conspiracy to fix prices paid to pharmacies for reimbursement of prescription drug claims. “This case involves an unlawful price-fixing agreement among several PBMs—orchestrated by the PBM rate aggregator, GoodRx—to suppress the prices paid to independent pharmacies for generic drugs,” according to one complaint filed Nov. 1 in the U.S. District Court for the Central District of California by an independent pharmacy, Community Care. The complaints allege that when a pharmacy submits claims for reimbursement from a pharmacy benefit manager and the patient pays with a discount card, that PBM uses GoodRx’s pricing software to determine whether another PBM offers a lower discount card price. If they find one with a lower price, the claim is rerouted to that PBM, which minimizes the reimbursements paid to pharmacies.

• The Need for Regulation to Positively Impact Drug Formulary Decisions to Ensure Appropriate Patient Access: A Little-Discussed Topic in Pharmaceutical Policy and Pricing Debate. Most recently, PBMs have received an increasing amount of scrutiny. Two areas that have received significant attention are the PBMs’ impact on drug pricing and the lack of transparency in their business practices. One issue that has not received a great deal of attention is the misuse of the drug formulary—the foundation of the drug benefit—which consists of a list of medications covered by one’s health insurance. Although some would say that the purpose of drug formularies has remained the same over the past 30-plus years, others would disagree. Initially, drug formularies were developed by a pharmacy and therapeutics committee of a PBM, health plan, or other organization. The committee was made up primarily of clinicians and other experts who determined the safety, efficacy, and unique clinical aspects of the drug. If it met their standards, it was placed on the formulary.

The pharmacy benefits management (PBM) landscape is constantly evolving, prompting plan sponsors to prioritize metrics that deliver actionable insights into their prescription drug spending. One such emerging metric is the Specialty Dispensing Rate (SDR). Understanding and optimizing SDR can play a crucial role in managing costs and evaluating PBM performance. This blog will introduce SDR, explain its importance, and illustrate its impact through practical examples presented in tables.

What Is the Specialty Dispensing Rate (SDR)?

The Specialty Dispensing Rate (SDR) is defined as the percentage of all dispensed prescriptions that are specialty drugs. Specialty drugs are high-cost medications used to treat complex, chronic conditions such as cancer, rheumatoid arthritis, and multiple sclerosis. These drugs often require special handling, administration, or monitoring.

Calculation of SDR:

SDR = (Number of Specialty Drug Prescriptions / Total Number of Prescriptions) x 100

Why Is SDR Important?

Specialty drugs, while accounting for a small percentage of total prescriptions, represent a sizable portion (∽50%) of total drug spending due to their high costs. By tracking SDR, plan sponsors can:

• Evaluate PBM Performance: A higher SDR may indicate that a PBM is not effectively managing specialty drug utilization, potentially leading to unnecessary costs.
• Manage Costs: Understanding SDR helps identify trends in specialty drug usage, allowing for targeted interventions to control spending.
• Improve Patient Outcomes: By monitoring SDR, plan sponsors can ensure appropriate use of specialty medications, enhancing patient care.

Impact of SDR Differences: Practical Examples

Let’s illustrate how differences in SDR can impact overall drug spending using two examples.

Assumptions:

• Average Cost of a Non-Specialty Prescription: $100
• Average Cost of a Specialty Drug Prescription: $8,500 per 28-day supply
• Analysis Considers SDRs of 1%, 2%, 3%, 4%, 5%, and 6%

Specialty Dispensing Rate increases might seem modest on paper but have substantial financial repercussions in practice. In example two, raising the SDR from 3% to 4% would result in an additional cost of $4,569,600. If the rate were increased to 5%, the extra expense would climb to $9,130,800. Pushing the SDR even further to 6% would amplify the additional cost to a staggering $13,700,400! These insights highlight the significant impact that small percentage changes in the SDR could have on self-insured employers’ overall financial obligations.

Action Steps for Plan Sponsors:

1. Establish a Baseline SDR: Know where you stand to measure progress effectively.
2. Monitor Regularly: Keep a close eye on SDR trends and associated costs.
3. Engage Stakeholders: Collaborate with PBMs, healthcare providers, and patients to manage specialty drug utilization.
4. Implement Cost-Saving Strategies: Use the insights gained to optimize your pharmacy benefit plan.

Conclusion

TransparentRx’s Solution Stacking cost management process tackles rising specialty dispensing rates (SDR) head-on, ensuring specialty drugs are dispensed only when clinically necessary and at the lowest possible cost. Each step in the process—from TransparentPA® reviews to identify cost-effective alternatives to Transparent340B’s discounted pharmacy network—reduces unnecessary specialty drug utilization. Tools like TransparentPGx® optimize medication selection through genetics, while TransparentMTM® provides ongoing medication therapy management, ensuring the appropriate prescribing and efficient management of specialty drugs.

This comprehensive approach enables plan sponsors to monitor and control SDR, which is a key driver of pharmacy costs. TransparentRx provides the transparency and strategic insights needed to optimize specialty drug utilization, reduce costs, and improve patient outcomes—all while ensuring a fiduciary standard of care.

Barron’s exposé details the role of PBMs in possibly fueling the opioid crisis and other notes from around the interweb:

• Shedding Light On Payers And PBMs As Possible Drivers Of Opioid Crisis. A recent Barron’s exposé details the role of PBMs in possibly fueling the opioid crisis. PBMs are important intermediaries in the prescription drug ecosystem, wielding power over which medications patients have access to and how much they cost. What the Barron’s article doesn’t emphasize is that PBMs serve at the behest of payers, which include employers, health plans and government agencies. On behalf of payers, PBMs negotiate net prices for drugs in conjunction with determining their positioning on formularies, or lists of covered medicines.

• Copay Adjustment Programs: What Are They and What Do They Mean for Consumers? Americans spend on average more than $1,000 per person per year on prescription drugs, far surpassing prescription drug spending in other peer nations. According to a 2023 KFF poll, 3 in 10 adults taking prescription drugs report that they have not taken their medication as prescribed due to costs. In a 2023 KFF consumer survey, nearly one-quarter (23%) of insured adults reported that their health insurance did not cover a prescription drug or required a very high copay for a drug that a doctor prescribed, increasing to more than one-third (35%) of insured adults in fair or poor physical health. People who need specialty or brand-name medications to treat chronic health conditions such as diabetes, cancer, arthritis, and HIV are especially vulnerable to high costs, particularly considering rising deductibles over the years.

• Pharmacies Accuse GoodRx of ‘Inviting Price-Fixing’ in Series of Antitrust Class Actions. The plaintiff pharmacies alleged that GoodRx, a prescription discount card aggregator, and four of the largest pharmacy benefit managers (PBMs) engaged in a conspiracy to fix prices paid to pharmacies for reimbursement of prescription drug claims. “This case involves an unlawful price-fixing agreement among several PBMs—orchestrated by the PBM rate aggregator, GoodRx—to suppress the prices paid to independent pharmacies for generic drugs,” according to one complaint filed Nov. 1 in the U.S. District Court for the Central District of California by an independent pharmacy, Community Care. The complaints allege that when a pharmacy submits claims for reimbursement from a pharmacy benefit manager and the patient pays with a discount card, that PBM uses GoodRx’s pricing software to determine whether another PBM offers a lower discount card price. If they find one with a lower price, the claim is rerouted to that PBM, which minimizes the reimbursements paid to pharmacies.

• The Need for Regulation to Positively Impact Drug Formulary Decisions to Ensure Appropriate Patient Access: A Little-Discussed Topic in Pharmaceutical Policy and Pricing Debate. Most recently, PBMs have received an increasing amount of scrutiny. Two areas that have received significant attention are the PBMs’ impact on drug pricing and the lack of transparency in their business practices. One issue that has not received a great deal of attention is the misuse of the drug formulary—the foundation of the drug benefit—which consists of a list of medications covered by one’s health insurance. Although some would say that the purpose of drug formularies has remained the same over the past 30-plus years, others would disagree. Initially, drug formularies were developed by a pharmacy and therapeutics committee of a PBM, health plan, or other organization. The committee was made up primarily of clinicians and other experts who determined the safety, efficacy, and unique clinical aspects of the drug. If it met their standards, it was placed on the formulary.

Formulary management can make or break the value of your pharmacy benefit program. It’s a term often tossed around, but many self-insured employers aren’t aware of the intricate mechanics that can either reduce their costs effectively or skyrocket them unnecessarily. Let’s dive into unpacking the complexity of formulary management; what a formulary is, how to assess its impact, and the common pitfalls that employers face when relying solely on rebate-driven solutions.

What Is a Formulary’s Primary Goal and Why Should You Care?

A formulary is a curated list of medications covered by a health plan, carefully designed to balance effective treatment with cost considerations. The primary goal is to ensure patients receive the most appropriate medication for their condition in a cost-effective manner. However, today’s formularies have often moved away from this purpose, transforming instead into a financial tool that prioritizes profit over patient care.

For self-insured employers, understanding what drives these lists is crucial. The choices made during formulary creation can significantly impact patient outcomes, employee satisfaction, and ultimately, your overall healthcare spend.

Evaluating Your Formulary and Utilization Management Program

How do you know if your formulary is working efficiently? Evaluating a formulary involves understanding the key metrics that reflect its performance:

1. Generic Dispensing Rate (GDR): This metric shows the percentage of prescriptions filled with generic drugs instead of brand names. Generics offer the same therapeutic value at a fraction of the cost, and a high GDR is often indicative of cost-effective formulary management.
2. Generic Substitution Rate (GSR): Similar but distinct from GDR, GSR represents how often generics are substituted when a brand-name drug is prescribed. High substitution rates suggest an effort to reduce costs without compromising quality.
3. Prior Authorization (PA): PA requirements are intended to ensure that only medically necessary prescriptions are approved, controlling inappropriate use. However, when PA is rubberstamped or when the PBM owns a specialty pharmacy, it can lead to conflicts of interest and undermine clinical appropriateness. Instead of genuinely evaluating the necessity of a medication, these PAs can become mere formalities, designed to channel prescriptions through the PBM’s specialty pharmacy—often at a higher cost. This practice creates unnecessary hurdles for patients and inflates costs for employers, all while sacrificing the intended clinical oversight.
4. Appeal Approval Rates: If many PA denials are being overturned on appeal, it may indicate that the formulary isn’t aligned well with actual clinical needs. When appeals are rubberstamped or primarily exist to protect the PBM’s financial interests, particularly if the PBM also owns the specialty pharmacy, it can mean that the initial denial was never based on clinical reasoning in the first place. High appeal approval rates can signal that the formulary management process is more about protecting profit margins than ensuring patients receive the medications they need.

The Risks of Rebate-Driven Formularies

Rebates sound like a good deal—a way to get money back from manufacturers. But when PBMs prioritize rebates in formulary decisions, it often leads to higher overall drug spend. Why? Because rebate-driven decisions incentivize expensive brand-name drugs over equally effective, cheaper alternatives. These formularies don’t prioritize clinical appropriateness; they prioritize financial incentives, leaving your employees to foot the real costs in the form of unnecessary treatments, side effects, or lack of access to needed medications.

Take, for example, a patient like Joanne, a 49-year-old woman with diabetes. When her medication was removed from the formulary for purely financial reasons, she had to switch treatments—resulting in multiple doctor’s visits, lab tests, and months of discomfort before regaining control of her condition. The real kicker? While the medication switch saved a few dollars on the unit price, the total cost—both financial and human—far exceeded what was saved.

PBM Consultants Overlook Clinical Management—To Everyone’s Detriment

Many PBM consultants or PBCs focus primarily on rebates and discount guarantees when evaluating potential savings, but clinical management is where the real cost control happens. Formularies should be tools for clinical value—not profit generation. By neglecting clinical focus, PBM consultants miss an opportunity to truly manage costs, improve outcomes, and ensure employee health remains the priority.

A clinical-first formulary keeps the patient’s needs in focus, balancing efficacy and cost-effectiveness. When rebates and discounts drive the conversation, you end up managing the price of each pill rather than the value of the overall treatment—often leading to a “penny wise, pound foolish” scenario.

Reclaiming Control—How TransparentRx Can Help

Navigating formulary management is challenging, but it’s not impossible. TransparentRx uses a fiduciary model that guarantees every decision is in the best interest of the patient—and by extension, the employer. By moving away from rebate-driven formularies and aligning formulary decisions with clinical best practices, we help you optimize your pharmacy benefit program, ultimately reducing costs without sacrificing patient outcomes.

With the right approach to formulary management, you can be confident that your pharmacy benefits program isn’t just reducing costs—it’s ensuring your employees have access to the medications they need, without unnecessary hurdles or additional financial burden.

The Need for Regulation to Positively Impact Drug Formulary Decisions to Ensure Appropriate Patient Access: A Little-Discussed Topic in Pharmaceutical Policy and Pricing Debate other notes from around the interweb:

• The Need for Regulation to Positively Impact Drug Formulary Decisions to Ensure Appropriate Patient Access: A Little-Discussed Topic in Pharmaceutical Policy and Pricing Debate. Most recently, PBMs have received an increasing amount of scrutiny. Two areas that have received significant attention are the PBMs’ impact on drug pricing and the lack of transparency in their business practices. One issue that has not received a great deal of attention is the misuse of the drug formulary—the foundation of the drug benefit—which consists of a list of medications covered by one’s health insurance. Although some would say that the purpose of drug formularies has remained the same over the past 30-plus years, others would disagree. Initially, drug formularies were developed by a pharmacy and therapeutics committee of a PBM, health plan, or other organization. The committee was made up primarily of clinicians and other experts who determined the safety, efficacy, and unique clinical aspects of the drug. If it met their standards, it was placed on the formulary.

• Copay Adjustment Programs: What Are They and What Do They Mean for Consumers? Americans spend on average more than $1,000 per person per year on prescription drugs, far surpassing prescription drug spending in other peer nations. According to a 2023 KFF poll, 3 in 10 adults taking prescription drugs report that they have not taken their medication as prescribed due to costs. In a 2023 KFF consumer survey, nearly one-quarter (23%) of insured adults reported that their health insurance did not cover a prescription drug or required a very high copay for a drug that a doctor prescribed, increasing to more than one-third (35%) of insured adults in fair or poor physical health. People who need specialty or brand-name medications to treat chronic health conditions such as diabetes, cancer, arthritis, and HIV are especially vulnerable to high costs, particularly considering rising deductibles over the years.

• Analysis finds that after 2 years GLP-1 drugs for weight loss don’t justify their price. Patients who have taken popular GLP-1 medications for weight loss aren’t saving themselves or their health plans any money, at least not right away. Eagan-based pharmacy benefits manager Prime Therapeutics issued that disappointing finding this week after analyzing the health care spending of thousands of patients who started taking GLP-1 medications in 2021, comparing them with similar patients who didn’t take the drugs. Spending was $4,206 higher per patient the year after they started taking the GLP-1 medications compared to the group of patients who didn’t take it, primarily because of the costly medications themselves. “It’s too soon to conclude whether these drugs will have a return on investment from a total cost of care perspective,” said David Lassen, Prime’s vice president of primary clinical services. “We didn’t expect to see that in two years, but we were hopeful that we would start to see something!”

• ‘Biosimilar’ drugs are gaining market share, Tufts researchers find. Biosimilars drugs are almost identical copies of original biologic products. Early biosimilars had slower adoption and savings than expected; however, biosimilars launched in recent years have had more success. With several biosimilar launches planned in the next few years, it is important to understand how the state of the market might foretell significant market savings in the future. To do so, we explored how the introduction of biosimilars affected originator-biosimilar markets during the period 2017–22. We found that after biosimilar availability, payers increasingly allowed choice of preferred products. By 2022, 76 percent of commercial payers’ coverage policies listed two or more products (originator or biosimilar) as first-line options. Biosimilar market shares exceeded those of originators by a mean of three years after the first biosimilar launch, and originator-biosimilar market average sales price declined substantially. Taken together, these findings provide evidence of a functioning competitive market.