This document presents a detailed evaluation of the top 10 clinical programs offered by pharmacy benefit managers (PBMs), which are pivotal for optimizing drug management and enhancing patient care while maintaining cost-effectiveness. The evaluation of top 10 pharmacy benefit manager clinical programs is methodically ranked, each program focusing on various aspects of clinical pharmacy benefit management.

1. Formulary Management: Topped by dynamic formulary adjustments, this program ensures regulatory compliance and the integration of clinical evidence to drive value-based decisions.
2. Specialty Pharmacy Management: This handles complex conditions through specialty pharmacies, emphasizing treatment adherence and efficiency.
3. Prior Authorization: Focused on fraud and waste prevention, this program maintains robust prior authorization processes with an approval rate below 70%.
4. Disease Management: Offers disease-specific guidelines and regular patient monitoring to enhance patient safety and health outcomes.
5. Medication Therapy Management (MTM): A comprehensive review of patient medications is combined with education and adherence programs to improve health impacts.
6. Benzodiazepine Management: This focuses on safe prescribing practices and patient education regarding the risks associated with benzodiazepines.
7. Generic Substitution: Promotes the use of generic drugs to enhance cost transparency and increase generic dispensing rates.
8. Medication Adherence: Utilizes medication synchronization and refill reminders to improve the proportion of days covered.
9. Opioid Management: Enforces guidelines on opioid prescribing, patient education on risks, and drug take-back options to manage opioid use effectively.
10. Step Therapy: Implements clear, evidence-based guidelines for medication sequences to ensure clinical and cost-effectiveness.

Each program is backed by best practices and involves key stakeholders like Pharmacy Directors, Healthcare Providers, and Pharmacy & Therapeutics Committees, ensuring a holistic approach to pharmacy benefits management. This ranking is crafted to assist Chief Human Resources Officers (CHROs) and Chief Financial Officers (CFOs) in making informed decisions about which clinical programs can best meet their organizational needs, align with financial goals, and ensure patient safety and satisfaction.

New lawsuit targets opioid pharmacy benefit managers and other notes from around the interweb:

• New Lawsuit Targets Opioid Pharmacy Benefit Managers. The case is before federal Judge Dan Aaron Polster of the United States District Court for Northern Ohio based in Cleveland. “Judge Polster recently opened a new bellwether track of cases against Express Scripts and OptumRx, two of the three PBMs with the largest market share in the United States,” according to the National Opioid Litigation letter. The other company in that top three is CVS Caremark, a subsidiary of CVS Health, that was included in a recent $10 billion settlement that also involved Walgreens…”About those companies, Marcus told the commissioners, “They chose profits over doing the right thing.”

• Fiduciary Duty Update: PBM Audit is Now Mandatory Protocol. The revelation that a drug costing over $10,000 in the market could be sourced for $28.40 has sent shockwaves through the industry, illustrating a glaring oversight in PBM management. Auditing your PBM is not merely a best practice; it is a critical safeguard against financial inefficiency and legal liabilities. Audits reveal discrepancies in billing, conflicts of interest, and non-compliance with contract terms — issues that, if unaddressed, could lead to breach of fiduciary claims.

• Audit of the American Postal Worker’s Union Health Plan’s Pharmacy Operations. “We found that the PBM overcharged the Carrier and the FEHBP $44,882,688 (including lost investment income) by not passing through all discounts and credit related to prescription drug pricing that were required under the PBM Transparency Standards found in the Carrier’s contract with the OPM. Specifically, our audit identified the following six findings that require corrective action. The findings occurred across all years of the auto scope unless otherwise noted.”

• Why Are Cash Prices Lower Than Health Insurance Negotiated Prices? Growing evidence demonstrates a counterintuitive phenomenon in healthcare: the cash price is often cheaper than insurance prices for the same service or product. Cash prices are unilaterally determined by a provider, while insurance prices are bilaterally negotiated between a provider and an insurance company. Don’t insurance companies presumably possess more bargaining power than individual patients? Our study found that among common shoppable services—such as lab tests, imaging, and joint replacements—half of U.S. hospitals set cash prices lower than their median insurance negotiated prices. Cash price being cheaper than insurance prices has also been documented for prescription drugs.

Ranking the top utilization management (UM) programs used by Pharmacy Benefit Managers (PBMs) can be complex due to the proprietary nature of specific tools and strategies employed by different organizations. However, several key types of UM programs are commonly recognized as effective in managing pharmacy benefits and controlling costs while ensuring patient care. Here’s TransparentRx’s ranking of the top ten pharmacy benefit manager utilization management programs:

Pharmacy benefits must be carefully managed to ensure people receive cost-effective treatment, improving their well-being and helping them lead happier, longer lives. This also enables employers to maintain a healthy and engaged workforce. These UM programs form the core of what many top PBMs use to manage drug utilization effectively. Each program has its strengths and plays a critical role in balancing cost containment with the provision of high-quality care. The specific effectiveness and ranking can vary depending on the specific health populations managed and the overall strategy of the PBM.

Audit of the American Postal Worker’s Union Health Plan’s Pharmacy Operations and other notes from around the interweb:

• Audit of the American Postal Worker’s Union Health Plan’s Pharmacy Operations. “We found that the PBM overcharged the Carrier and the FEHBP $44,882,688 (including lost investment income) by not passing through all discounts and credit related to prescription drug pricing that were required under the PBM Transparency Standards found in the Carrier’s contract with the OPM. Specifically, our audit identified the following six findings that require corrective action. The findings occurred across all years of the auto scope unless otherwise noted.”

• Why Are Cash Prices Lower Than Health Insurance Negotiated Prices? Growing evidence demonstrates a counterintuitive phenomenon in healthcare: the cash price is often cheaper than insurance prices for the same service or product. Cash prices are unilaterally determined by a provider, while insurance prices are bilaterally negotiated between a provider and an insurance company. Don’t insurance companies presumably possess more bargaining power than individual patients? Our study found that among common shoppable services—such as lab tests, imaging, and joint replacements—half of U.S. hospitals set cash prices lower than their median insurance negotiated prices. Cash price being cheaper than insurance prices has also been documented for prescription drugs.

• Fiduciary Duty Update: PBM Audit is Now Mandatory Protocol. The revelation that a drug costing over $10,000 in the market could be sourced for $28.40 has sent shockwaves through the industry, illustrating a glaring oversight in PBM management. Auditing your PBM is not merely a best practice; it is a critical safeguard against financial inefficiency and legal liabilities. Audits reveal discrepancies in billing, conflicts of interest, and non-compliance with contract terms — issues that, if unaddressed, could lead to breach of fiduciary claims.

• How GoodRx Helped Steal $7 From My Pharmacy. GoodRx, primarily known as a platform for obtaining prescription coupons and tracking drug prices, interacts with Pharmacy Benefits Managers (PBMs) in a way that’s distinct from traditional PBM operations. In essence, GoodRx leverages the existing PBM infrastructure to provide discounted prices directly to consumers, often bypassing the more traditional insurance-based prescription purchasing pathway. For benefits consultants and employers, understanding this interaction is crucial in advising on healthcare strategies that maximize both cost efficiency and patient outcomes. Employers need to consider how tools like GoodRx fit into a broader benefits design, particularly in terms of how they affect out-of-pocket costs for employees and the overall usage of pharmacy benefits managed under traditional PBM contracts.

In our webinar, “Revolutionizing Pharmacy Benefits by Disrupting the Status Quo and Driving Down Costs,” we delve into the innovative strategies reshaping the landscape of pharmacy benefits management (PBM). By challenging conventional approaches and implementing cutting-edge solutions, we’re driving down costs while enhancing patient outcomes.

Why You Should Watch:

1. Gain Insight: Learn about groundbreaking methodologies transforming pharmacy benefits, equipping you with the knowledge to navigate this evolving industry.
2. Cost Reduction Strategies: Discover practical approaches to reducing pharmacy costs without compromising the quality of care, crucial for businesses seeking to optimize their healthcare spending.
3. Patient-Centric Solutions: Explore how our innovative techniques prioritize patient well-being, ensuring better health outcomes while containing expenses.
4. Industry Disruption: Stay ahead of the curve by understanding the latest disruptions in the PBM sector and how they can benefit your organization.
5. Fiduciary Standard of Care: Understand the importance of adopting a fiduciary standard of care in pharmacy benefits management, aligning with best practices and ethical standards.

Who Should Watch:

• Benefits Consultants: Enhance your expertise in PBM to better serve your clients and provide them with actionable strategies to control healthcare costs.
• Human Resources Managers: Gain insights into innovative approaches for managing pharmacy benefits, helping you make informed decisions that benefit your employees and your bottom line.
• Employers: Learn how to optimize your pharmacy benefits program to achieve cost savings while ensuring your employees receive high-quality care.
• Healthcare Professionals: Stay abreast of industry trends and advancements in pharmacy benefits management, enabling you to deliver more effective patient care within your organization.

Watch on-demand as we revolutionize pharmacy benefits together, driving down costs while prioritizing patient well-being. Let’s disrupt the status quo and shape the future of healthcare together!

In today’s rapidly evolving healthcare landscape, managing pharmacy benefits is not just about containing costs—it’s about crafting a synergy of quality care, accessibility, efficiency, and participant satisfaction. At TransparentRx, we understand that every aspect of pharmacy benefit design can significantly impact the health and well-being of the participants it serves. Let’s delve into the four broad issues that underpin an effective pharmacy benefit design.

1. Quality: The Pillar of Care

Quality in pharmacy benefits is threefold: care structure, processes, and outcomes. A robust care structure is foundational, ensuring that participants have access to essential medications without unnecessary delays or hurdles. The process, from prescription to pill delivery, must be streamlined, clear, and consistently monitored for potential improvements.

Outcomes are the ultimate measure of quality. At TransparentRx, we prioritize the clinical effectiveness of the medications provided and the positive health outcomes for the participant. This includes not only the resolution of the condition being treated but also monitoring for potential drug abuse, interactions, and side effects.

2. Accessibility: Removing Barriers

Accessibility goes beyond the physical availability of medications. It encompasses the elimination of financial, transportation, and geographical barriers that participants may face. TransparentRx champions affordable options without sacrificing quality. Whether it’s negotiating better prices or embracing mail-order services, we ensure that medications are within reach, both geographically and financially.

Transportation and geographical challenges are addressed by a network of pharmacies and the use of innovative delivery methods. By enhancing our telehealth and mail-order services, we bring the pharmacy to the participant’s doorstep, no matter where they live.

Understanding the distinctions between effective and ineffective benefit design practices is crucial. Below, we present a table contrasting strong (good) examples of benefit design with practices that should be avoided (bad) for each of the four broad issues:

By recognizing the stark contrast between these examples, employers, brokers, and consultants can more effectively evaluate and select pharmacy benefit plans that align with the fiduciary standard of care and participant-centric values. TransparentRx stands ready to guide you through the intricacies of these issues, ensuring that your pharmacy benefit design is both cost-effective and highly beneficial to your participants.

3. Efficiency: Maximizing Resources

Efficiency in pharmacy benefit design means accomplishing plan objectives with the least expensive combination of resources—without compromising on quality. At TransparentRx, we leverage InsourceRx data analytics to understand usage patterns, eliminate waste, and prevent fraud.

We assess the therapeutic equivalents and generic options, ensuring the most cost-effective medications are available. By balancing the cost against clinical effectiveness, we provide a plan that respects both the participant’s health and the bottom line.

4. Participant Satisfaction: The Heart of Our Mission

The true measure of a successful pharmacy benefit design is participant satisfaction. It reflects the ease of using the plan, the quality of the interactions with pharmacy staff, and the clarity of information provided. TransparentRx takes pride in our Net Promoter Score (NPS) of 86, which is a testament to our commitment to participant satisfaction.

This score significantly surpasses the industry average NPS for pharmacy benefit managers, reflecting the exceptional experience participants have with our services. An NPS of 86 indicates that a vast majority of our clients are not just satisfied, but are enthusiastic advocates for our brand, confident in recommending our services to others.

Conclusion

Pharmacy benefits management is a complex, multifaceted endeavor. By focusing on quality, accessibility, efficiency, and participant satisfaction, TransparentRx crafts a pharmacy benefits plan that not only meets but exceeds expectations. Our commitment to a fiduciary standard of care ensures that every decision we make is in the best interest of the participants we serve—helping our nation look better, feel better, and live longer.

Reviewing PBM Alternative Pricing Models for CVS Health, ESI, and OptumRx and other notes from around the interweb:

• Reviewing PBM Alternative Pricing Models For CVS Health, ESI, and OptumRx. PBM alternative pricing models are being rolled out by some of the biggest organizations in the industry in response to mounting political pressure, changing legislation, and the prevalence of industry disruptors. PSG has closely assessed the strategies put forward by CVS Health, ESI, and OptumRx regarding pharmacy reimbursement and client pricing models. We will take a deeper look at network contracting strategies like CVS CostVantage and ESI ClearNetwork in addition to client pricing strategies such as CVS Caremark TrueCost, ESI ClearCareRx, OptumRx Cost Advantage, and OptumRx Cost Clarity and share some considerations for how plan sponsors should address the changing pricing landscape.

• GLPs Are the Latest Example of the Shift to Alternative Purchasing Models. Prior to the rollout of Medicare Part D in 2006, the Medicare population represented the largest out-of-pocket consumer group in the cash pay marketplace. Then it was the uninsured prior to the Affordable Care Act (ACA). Then, after the ACA exchanges and Medicaid expansion, the cash pay strategy turned to middle- and upper middle–class households, with the fewest regulatory restrictions, the most disposable income, and, importantly, the highest deductibles for drug coverage. Many of these individuals had to spend many thousands of dollars for first dollar coverage. A large swath of the American population has now become accustomed to not even bothering with their pharmacy benefit manager (PBM), and the first question that comes to mind isn’t “Does my insurance cover it?” but rather, “What’s the easiest and most convenient way for me to get a prescription for the drug I saw on my social media feed?”

• Explainer: Why are US pharmacy benefit managers under fire? Separate bills aim to ban what is known as “spread pricing,” a practice in which PBMs charge health plans a larger amount for a drug than they pay out to pharmacies. Some are seeking more transparency under which the companies would be required to provide more information on their non-public negotiations. Rebates have also been a subject of proposed new government rules. The Trump administration sought in 2020 to make rebates illegal for Medicare prescription drug plans by removing the safe harbor protection that shields rebates from federal anti-kickback laws. The Biden administration delayed the rule until 2023 and Congress further delayed it until 2027.

• How GoodRx Helped Steal $7 From My Pharmacy. GoodRx, primarily known as a platform for obtaining prescription coupons and tracking drug prices, interacts with Pharmacy Benefits Managers (PBMs) in a way that’s distinct from traditional PBM operations. In essence, GoodRx leverages the existing PBM infrastructure to provide discounted prices directly to consumers, often bypassing the more traditional insurance-based prescription purchasing pathway. For benefits consultants and employers, understanding this interaction is crucial in advising on healthcare strategies that maximize both cost efficiency and patient outcomes. Employers need to consider how tools like GoodRx fit into a broader benefits design, particularly in terms of how they affect out-of-pocket costs for employees and the overall usage of pharmacy benefits managed under traditional PBM contracts.

In the realm of pharmacy benefit management (PBM), grasping the full scope of costs is crucial for Directors of Benefits and CFOs who strive to optimize their healthcare investments. It’s essential to recognize that the “price” of drugs is not synonymous with “cost.” True cost management requires a nuanced understanding of four primary cost drivers: price, product mix, utilization, and cost share. Let’s delve into each of these components to provide a clearer strategy for managing pharmacy benefits effectively.

Price

Definition: The price is the amount paid for a drug to the manufacturer or pharmacy after accounting for rebates and discounts.

Components:

• List Price: Manufacturer’s initial price for the drug.
• Net Price: Actual price paid after subtracting rebates and discounts provided by manufacturers to payers and PBMs.
• Markup: Additional costs added by pharmacies or PBMs.

Effective strategies to manage drug prices include negotiating better rebate terms, choosing generics or biosimilars where appropriate, and leveraging competitive bids for PBM contracts.

Product Mix

Definition: Product mix refers to the composition of prescription drugs dispensed under a benefit plan.

Components:

• Generic Dispense Rate (GDR): The proportion of all dispensed prescriptions that are generics, which are typically cheaper than brand-name drugs, should be 88% or higher. Every 1% increase in GDR leads to 5% gross cost savings.
• Therapeutic Alternatives: Use of clinically equivalent drugs that vary in price.
• High-cost Drugs: Biologics and specialty drugs that significantly impact overall spending.

Strategies for optimizing the product mix involve increasing the generic dispensing rate, formulary management to encourage the use of cost-effective therapeutic alternatives and implementing step therapy policies, for example.

Utilization

Definition: Utilization measures the volume or frequency of drug dispensation under a health plan.

Components:

• Prescription Volume: Total number of prescriptions filled.
• Days Supply: Prescribed amount and the length of time for which a drug is dispensed.
• Member Population Health: The overall health demographics of the covered population which influences disease prevalence and drug usage.

Managing utilization entails using data analytics to forecast trends, implementing medication therapy management (MTM) programs to mitigate risk, and employing utilization management tools like prior authorization. Prior authorization approval rates are lower than 70% for efficient pharmacy benefit management programs.

Cost Share

Definition: Cost share refers to the distribution of drug expenses between the insurance plan and its beneficiaries.

Components:

• Deductibles: The amount a beneficiary must pay out-of-pocket before the health plan starts paying.
• Copayments and Coinsurance: Fixed amounts or percentages of the prescription cost that a beneficiary is responsible for after meeting their deductible.
• Out-of-Pocket Maximums: The maximum amount a beneficiary pays in a year, after which the plan covers 100% of additional costs.

To optimize cost sharing, strategies include adjusting plan design to influence drug choices through differential copays for generics versus brands and using tiered formularies to incentivize lower-cost options.

Conclusion

For Directors of Benefits and CFOs, understanding these four cost drivers and their components is critical not just for managing expenses, but also for improving patient outcomes without compromising care quality. By integrating strategic management of price, product mix, utilization, and cost sharing, organizations can achieve a more sustainable and efficient pharmacy benefit framework that upholds a fiduciary standard of care. This comprehensive approach ensures that costs are contained not by cutting corners, but by enhancing the value delivered to beneficiaries.

Mayo Clinic employee files class action lawsuit over high health care costs and other notes from around the interweb:

• Mayo Clinic employee files class action lawsuit over high health care costs. The worker, who is unnamed in the lawsuit, is seeking reimbursement for the money they allege they overpaid for care that should have been reimbursed — as well as for the thousands of other Mayo Clinic employees and Medica customers they believe are similarly situated and paid more than they should have for care. The lawsuit alleges Medica, which administers Mayo Clinic’s self-insured plan, uses “deceptive, misleading, arbitrary” pricing methods that leave plan members in the dark about health costs and allow for inconsistent reimbursement rates, in violation of federal law and Medica’s fiduciary responsibilities.

• Mark Cuban: Five Ways that Big PBMs Hurt U.S. Healthcare–And How We Can Fix It. #1 Zero transparency. The number one rule when contracting with PBMs is that you don’t talk about the PBMs and their contracts. They prevent everyone–providers, manufacturers, employers, and non-affiliated pharmacies—from making public or discussing their pricing terms or any aspect of their contracts. If you do, they’re happy to sue you.

• Amid increased federal scrutiny, PBMs pivot strategy to further squeeze independent pharmacies. Pharmacy benefits managers (PBMs) are employing new strategies to squeeze independent pharmacies, even as the industry faces pressure from the federal government, which is looking for ways to curb healthcare’s middlemen and preserve competition in medicine distribution. Independent pharmacies have complained for years about unfair tactics used by PBMs to force them out of business, including underpaying for filled prescriptions and reimbursement clawbacks. It has gotten the attention of Congress, and the Federal Trade Commission (FTC) is in the middle of a probe with results due this year. Meanwhile, another tactic is starting to see an anecdotal increase: terminations.

• It’s time for facts in the PBM debate. You’ve also likely heard recently from Mark Cuban, who has an emerging side hustle as a pharmacy expert. His company, Mark Cuban Cost Plus Drugs, has a narrow offering, and focuses on the cost of generic drugs. That’s a problem that has already been solved. Over the past decade, many organizations have built sophisticated businesses focused on reducing the cost of generic drugs in this country. The reality is, the Cost Plus offering is neither novel nor unique—it is a generic sourcing business that is 10 years too late. What’s more, it often lacks a consistent supply of products and regularly stocks treatments with short expiration dates, failing to offer the comprehensive and reliable service needed to deliver high-quality pharmacy benefits to a large patient population.