The Employer's Guide Blog for Overseeing PBMs

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7 Steps for Effectively Managing Costs of Specialty Drugs

Payers continue to be challenged by rapidly rising prescription drug costs, particularly specialty drugs.  However, traditional [and some transparent] Pharmacy Benefit Managers offer the same elixir for controlling these costs as they did a decade ago: increase patient use of mail-order, use of preferred or narrow pharmacy networks, a formulary design which promotes preferred drugs, reduce patient co-pays for better outcomes blah…blah…blah…

While the aforementioned tactics do assist in controlling costs, they’re standard practice and are not the aggressive measures necessary to help reduce or control spending.  An excellent PBM is one which truly puts its clients and their members first; before shareholders and profitability.  Hire the right PBM, one willing to follow through on these 7 steps, and you’ll surely rein in rising drug costs.

  1. Hire a PBM willing to sign on as a fiduciary; transparent speak isn’t enough.
  2. Promote member use of manufacturer coupons for brand and specialty drugs. PBMs should communicate availability of all coupons to members. 
  3. Pay only Cost Plus (no spreads or mark-ups) for all prescription drugs.
  4. Include a semi-annual market check in the contract language. 
  5. Attain and exercise full auditing rights. 
  6. Require the PBM to identify and pass along all sources of attributable revenue from manufacturers.  Limiting agreements to ‘rebates’ leaves money on the table.
  7. Use Reference Pricing — different and much more effective (when applied) than an AWP reporting service.
*Cost Plus = [Acquisition Cost + dispensing fee + admin fee] minus Co-pay

Due in large part to specialty drugs, we are clearly entering a time of higher costs. Payers whom act now are in the best position to assure continued access to quality care for their members while effectively managing rising drug costs.

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.

This Post Has 2 Comments

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    Yes plan sponsors should demand full insight into manufacturer contracts for rebates and invoices from specialty pharmacies or 835 remittance advice.

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