The Employer's Guide Blog for Overseeing PBMs

The Definition of Oversee: to watch over and direct (an undertaking, a group of workers, etc.) in order to ensure a satisfactory outcome or performance.

3 ways PBMs can team up with employers to save on specialty drugs

1. Improved care coordination and communication

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Controlling specialty spend is about supporting patients and working with their healthcare team to ensure that treatment is safe and effective. Medications that don’t work as they should translate to poor health outcomes, which drive up overall costs.

PBMs are perfectly positioned to work with all members of a patient’s healthcare team to improve communication. PBM pharmacists have access to all data gathered from prescription claims and, potentially, integrated medical claims data. This allows them to see a comprehensive picture of the patient’s medication history, diagnoses, lab results, indicators of adherence and other applicable medical data. As a result, PBM pharmacists can alert prescribers and retail pharmacists of any issues and facilitate the identification of safer, more effective treatment options.

2. Advanced clinical programs

To be able to provide effective care coordination, PBMs must also offer comprehensive, advanced clinical programs. Prior authorization provides an example of how clinical programs are not created equal. The intention of prior authorization is to make certain medications are used appropriately. But does the analysis review whether the medication is appropriate for a specific individual’s needs? Not all prior authorization programs do. A comprehensive program considers whether there are warnings and contraindications related to factors such as the patient’s age, health conditions, metabolism, lifestyle or other medications they may be taking.

3. Creative contracting and partnerships

Finally, plan sponsors need a PBM that works with them, putting the plan’s and patients’ best interests first while delivering ethical, transparent benefit management. They should consider PBMs that tie performance guarantees directly to their clinical programs. A pay-for-performance arrangement holds the PBM accountable for how well it facilitates responsible, effective drug utilization that reduces the plan’s spending.

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Tyrone Squires, MBA, CPBS

I am the proud founder and managing director of TransparentRx, a fiduciary-model PBM based in Las Vegas, Nevada. We help health plan sponsors reduce pharmacy spend, by as much as 50%, without cutting benefits or shifting costs to employees.

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