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.

In the world of pharmacy benefits management, formularies stand as a cornerstone, guiding the dispensation of medications based on efficacy, safety, and cost-effectiveness. For pharmaceutical manufacturers, understanding the nuances of different formulary types is crucial, as these can significantly influence rebate agreements and market access. Today, we delve into five types of formularies through the lens of pharmaceutical manufacturers, including the progressive value-based formulary, to uncover how each affects the dynamic landscape of pharmaceutical rebates.

1. Open

Open formularies offer the widest range of drugs, imposing few restrictions. This inclusivity means pharmaceutical manufacturers face less pressure to provide steep rebates to secure formulary placement. However, this openness can lead to higher overall drug costs for payers.

2. Closed

Closed formularies represent the other end of the spectrum, listing a more restricted range of drugs. For manufacturers, securing a spot on these formularies often necessitates offering substantial rebates. The exclusivity can drive competitive pricing but might limit patient access to certain drugs.

3. Tiered

Tiered formularies categorize drugs based on cost-sharing levels. Drugs in lower tiers cost patients less, incentivizing manufacturers to offer competitive rebates for favorable tier placement. This structure encourages cost efficiency while maintaining a range of options.

4. Preferred Drug Lists (PDLs)

PDLs highlight a subset of drugs within a formulary, chosen for their value in terms of efficacy and cost. Manufacturers may need to offer rebates or demonstrate superior value to get their drugs listed as preferred. This list can influence prescribing habits significantly.

5. Value-Based

Value-based formularies prioritize drugs based on their overall value to patient health outcomes, potentially adjusting cost-sharing to encourage the use of more effective treatments. Manufacturers whose drugs demonstrate high value may gain favorable placement without the same emphasis on rebates. This approach aligns costs more closely with outcomes. Each formulary type presents unique advantages and challenges for pharmaceutical manufacturers, especially concerning the negotiation of rebates.

Conclusion

The relationship between formulary management and pharmaceutical rebates is a dynamic and complex one. For pharmaceutical manufacturers, understanding and navigating the different formulary types is crucial to their strategy for securing formulary placement and optimizing rebate agreements. From the perspective of TransparentRx, leveraging this understanding allows us to negotiate better terms, ultimately benefiting our members through access to effective and affordable medications.

As the healthcare landscape evolves, so too will the strategies around formulary management and rebate negotiation. Staying informed and adaptable is key to navigating these changes effectively, ensuring that we continue to meet the needs of our members while fostering sustainable relationships with pharmaceutical manufacturers.

AI-Driven Solutions Promote Medication Adherence and other notes from around the interweb:

• AI-Driven Solutions Promote Medication Adherence. A study conducted in 2019 showed that approximately 50% of the 187 million patients in the US health care system did not follow their medication plan as prescribed. This means they failed to adhere to the drug regimen or to take the medication for the entire prescribed duration. Adherence rates for most medications used to treat chronic conditions, such as diabetes and hypertension, usually fall in the range of 50% to 60%, even with patients who have good insurance and drug benefits. This rate of adherence leads to an estimated 125,000 avoidable deaths each year and $100 billion annually in preventable health care costs.

• 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.

• 5 ways to improve your PBM procurement process in 2024. Many self-funded plan sponsors struggle to manage the cost of pharmacy benefits and rely on non-transparent contract guarantees to hold PBMs accountable. Meanwhile, drug spending continues to compound at an astonishing rate in defiance of the savings promised during the procurement process. As a former pharmacy program director for a plan covering more than 16,000 lives, I can tell you that it is possible to stop the “games” PBMs play, control costs, and ensure that all contractual guarantees are met, especially in scenarios where a PBM won’t guarantee an all-in per member per month (PMPM) cost for the year. Understanding the problem is a part of the solution, but making meaningful changes to the way plan sponsors and brokers evaluate PBMs is where the real opportunity lies.

In the realm of employee health and wellness, medication adherence plays a pivotal role in managing chronic conditions and reducing healthcare costs. For Chief Human Resources Officers (CHROs) and Chief Financial Officers (CFOs), ensuring high medication adherence rates among employees is not just a matter of health but also impacts the bottom line. This is where Advanced Pharmacy Benefit Management (PBM) steps in, offering strategic solutions to enhance medication adherence and optimize healthcare expenditures. Now, let’s explore how advanced PBM strategies can assist HR and finance leaders in improving medication adherence among employees:

1. Data-Driven Insights: Advanced PBMs leverage data analytics to identify trends and patterns in medication adherence among employee populations. By gaining insights into adherence behaviors, CHROs and CFOs can tailor targeted interventions and wellness programs to address specific adherence challenges within their workforce.
2. Cost-Effective Benefit Design: PBMs work closely with employers to design prescription benefit plans that incentivize medication adherence while managing costs effectively. Through strategies such as value-based formularies and patient-centric utilization management programs, CHROs and CFOs can optimize medication access while containing healthcare expenditures.
3. Healthcare Navigation Services: Some advanced PBMs offer healthcare navigation services to guide employees through their medication journey, from prescription initiation to refill management. By providing personalized support and resources, HR and finance leaders can empower employees to make informed decisions about their health and medication regimens.
4. Financial Impact Analysis: PBMs provide CHROs and CFOs with comprehensive reporting and analytics tools to assess the financial impact of medication adherence on overall healthcare spending. By quantifying the cost savings associated with improved adherence, HR and finance leaders can demonstrate the value of investing in adherence-enhancing initiatives.
5. Medication Therapy Management (MTM): This service involves personalized medication reviews and consultations conducted by pharmacists to optimize medication regimens, improve adherence, and minimize adverse effects. By engaging employees in one-on-one discussions about their medications, HR and finance leaders can enhance medication understanding and compliance.
6. Proportion Days Covered and Medication Possession Ratio: These metrics quantify medication adherence by assessing the percentage of time employees have access to their prescribed medications. Proportion Days Covered (PDC) measures the duration of medication supply coverage over a specific period, while Medication Possession Ratio (MPR) calculates the ratio of days medication is on hand compared to the total days in a set timeframe. By monitoring these metrics, HR and finance leaders can gauge the effectiveness of adherence initiatives and identify areas for improvement in employee health management strategies.

In summary, optimizing medication adherence through advanced Pharmacy Benefit Management is not only a strategic imperative for improving employee health outcomes but also a prudent financial decision for organizations. By leveraging data-driven insights, cost-effective benefit design, and personalized support services, CHROs and CFOs can drive positive health outcomes while maximizing the return on investment in employee healthcare benefits.

Study: Utilization management has ramped up in Part D and other notes from around the interweb:

• Study: Utilization management has ramped up in Part D. Utilization management in Medicare Part D has become more restrictive over the last decade, even when compared to Medicare Advantage prescription drug plans, according to a new study. The study, conducted by researchers at the University of Southern California and Blaylock Health Economics and published this week in Health Affairs, found an increase across multiple types of utilization management, including prior authorization, step therapy and formulary exclusions, between 2011 and 2020. On average, 31.9% of drugs were restricted in some fashion in 2011, which grew to 44.4% by 2020, according to the study. By the end of the study window, 44.7% of formularies restricted brand-name-only drugs.

• Best Pharmacy Benefit Consultants for Cost-Effective Drug Plans. In the complex world of healthcare and pharmaceuticals, managing costs while ensuring the best possible care can be a daunting challenge for businesses of all sizes. Pharmacy Benefit Consultants (PBCs) play a crucial role in navigating this landscape, offering expertise that can lead to significant savings and more effective drug plan management. This article delves into the importance of PBCs, what to look for when selecting a consultant, and how they can transform the cost-effectiveness of drug plans.

• 5 ways to improve your PBM procurement process in 2024. Many self-funded plan sponsors struggle to manage the cost of pharmacy benefits and rely on non-transparent contract guarantees to hold PBMs accountable. Meanwhile, drug spending continues to compound at an astonishing rate in defiance of the savings promised during the procurement process. As a former pharmacy program director for a plan covering more than 16,000 lives, I can tell you that it is possible to stop the “games” PBMs play, control costs, and ensure that all contractual guarantees are met, especially in scenarios where a PBM won’t guarantee an all-in per member per month (PMPM) cost for the year. Understanding the problem is a part of the solution, but making meaningful changes to the way plan sponsors and brokers evaluate PBMs is where the real opportunity lies.

• Mark Cuban to CEOs: ‘If you’re using a Big 3 pharmacy benefits manager, you are getting ripped off. Two years ago, Cuban’s companies were self-insured, with him effectively writing personal checks for out-of-pocket health care expenses. As Cost Plus Drugs got off the ground, he says he compared the prices of generic prescription medications he’d been paying for to those offered by his new pharmacy. “What we spent $160,000 on at the [Dallas Mavericks], we could have purchased for $19,000 for Cost Plus,” he tells Fortune. “We decided once that plan ended last year, we were going to replace it, and so I wanted to go through the entire process of understanding what I did right or wrong.” He first turned to the employee benefits consultant who had assured him he was getting a great deal—someone whose advice also cost $30 per employee per month. “That’s insane, that was millions of dollars,” Cuban says. “The person who put me into a program where I was paying eight times more than I should have for generic medication, they’re done.”

If you’re a big shot in HR, especially one looking to make a real difference in your company, this is for you. Let’s talk about something called pharmacy benefit management or PBM analytics. It’s all about making sure your team gets the medicine they need without breaking the bank. Sounds good, right? Here, we’re going to break down the must-know stuff (those fancy Key Performance Indicators or KPIs) that’ll help you rock your role and keep everyone healthy and happy.

Why PBM Analytics Matters

Pharmacy Benefit Management isn’t just about pills and prescriptions. It’s your secret weapon for keeping healthcare costs in check while making sure your crew gets the care they need. By diving into the data, you can spot ways to save money and boost health benefits.

The KPIs You Need to Know

1. Cost Per Member Per Month (PMPM): Think of this as the average amount of money spent on meds for each person every month. Keeping an eye on this can help you figure out where your money’s going and how to spend it smarter. Goal < $100 PMPM.
2. Generic Dispensing Rate (GDR): This one’s about choosing store-brand cereal instead of a fancy one. Generic meds are usually much cheaper than brand names, so a high GDR means you’re saving more dough. Goal > 90%. For every 1% you increase GDR, pharmacy costs decrease by as much as 5%! Increase GDR from 83% to 88% and your total pharmacy costs decrease by 25%, for example.
3. Medication Adherence Rate: This is all about making sure folks are taking their meds as prescribed. When they do, they’re healthier, and you won’t have to spend extra on doctor visits or other treatments. Goal > 80% PDC.
4. Specialty Drug Spend: Some meds are super expensive because they’re for rare or hard-to-treat conditions. Tracking this spending can help you find ways to manage costs better. Goal < 30% total drug spend.
5. Therapeutic Optimization: This fancy term just means making sure everyone’s getting the best possible treatment without overspending. It’s like getting the best bang for your buck. Goal > 98% GSR.
6. Plan Utilization: This is about seeing how everyone’s using their pharmacy benefits. Are they going for mail-order or picking up meds at the store? Knowing this can help you tweak the plan to make it better for everyone. Goal > 20% mail-order utilization measured by average days’ supply.

Making It All Work

Being a CHRO means you’ve got a vital role to play in making sure your team’s healthy and the company’s thriving. By focusing on these KPIs, you’ll be able to make smart moves that benefit everyone. And remember, you don’t have to be a data wizard to get this right. It’s all about keeping an eye on the right numbers and asking the right questions. So, there you have it! Dive into PBM analytics with these KPIs in your toolkit, and you’ll be setting your company up for success. It’s about making smart choices, saving money, and keeping everyone healthy. You’ve got this!

In the complex and rapidly evolving field of pharmacy benefits management (PBM), expertise is not just valuable; it’s essential. However, the terrain is fraught with self-professed experts whose credentials and experience may not stand up to scrutiny. This poses a significant risk to employers, unions, health plans, and health systems that rely on their guidance for managing pharmacy benefits, which are a critical and costly component of healthcare benefits. The risks of relying on self-professed pharmacy benefit experts and the value of certification can coexist; they are not mutually exclusive.

Fiduciaries, tasked with making decisions in the best interest of their beneficiaries, often turn to external experts for guidance, especially in areas outside their immediate expertise. This practice is not only prudent but expected under certain conditions to ensure well-informed decision-making. However, it’s crucial that fiduciaries do not simply take this external advice at face value. The Court of Appeals for the Third Circuit has highlighted a nuanced stance regarding this reliance. The court acknowledges the value of engaging consultants for their expertise in making informed investment decisions. Nonetheless, it emphasizes that fiduciaries under ERISA (the Employee Retirement Income Security Act) bear the responsibility to actively engage with the information provided by these consultants.

Pitfalls of Self-Professed Pharmacy Benefit Experts

Lack of Accountability

One of the primary risks of engaging with self-professed experts is the lack of accountability. Certified professionals, on the other hand, are accountable to the standards and ethics set forth by the certifying body, ensuring a minimum level of competence and integrity.

Inadequate Knowledge

Pharmacy benefits management is a specialized field that requires a deep understanding of cost management, benefit design, contract review, healthcare policy, and pharmaceutical pricing fundamentals. Self-professed experts may lack the comprehensive knowledge necessary to navigate these complexities effectively, potentially leading to suboptimal outcomes.

Bias and Conflicts of Interest

Without the transparency and ethical obligations required of certified professionals, self-professed experts may have undisclosed biases or conflicts of interest. This can lead to recommendations that serve the expert’s interests rather than those of their clients.

Benefits of Certified Pharmacy Benefits Specialists

For Unions

Unions benefit from certified specialists by ensuring their members and employees have access to the best possible pharmacy benefits at the lowest possible cost. Certified specialists are equipped to negotiate effectively with pharmacy benefits managers, identify cost-saving opportunities, and design benefits plans that meet the needs of diverse populations.

For Health Plans and Health Systems

Health plans and health systems face the dual challenge of managing costs while ensuring patient access to necessary medications. Certified Pharmacy Benefits Specialists (CPBS) bring a level of expertise that can help these organizations balance these objectives, through strategic formulary management, vendor selection, and compliance with regulatory requirements.

For Commercial and Public Sector Employers

Commercial and public sector employers, who often provide health benefits to large numbers of employees, stand to gain significantly from the expertise of certified specialists. These professionals can help employers navigate the complexities of pharmacy benefits management, including specialty drug coverage, benefit design, and wellness integration, leading to improved health outcomes and cost savings.

Conclusion

In an era where healthcare costs continue to rise, and the landscape of pharmacy benefits grows increasingly complex, the value of Certified Pharmacy Benefits Specialists (CPBS) cannot be overstated. By relying on certified professionals, unions, health plans, health systems, and employers can mitigate the risks associated with self-professed experts. Certification ensures that these critical stakeholders have access to knowledgeable, accountable, and ethical experts who are committed to optimizing pharmacy benefits in the best interest of their clients. The Certified Pharmacy Benefits Specialist (CPBS) program stands at the forefront of this effort, providing a benchmark for excellence and integrity in the field of pharmacy benefits management.

ERISA’s Cure for the $1.5 Trillion Health Benefits Market and other notes from around the interweb:

• Hiding in Plain Sight: ERISA’s Cure for the $1.5 Trillion Health Benefits Market. Fiduciaries are expected to consult outside experts to inform their decisions where the circumstances warrant but may not blindly rely on expert advice. As the Court of Appeals for the Third Circuit has explained, “While we would encourage fiduciaries to retain the services of consultants when they need outside assistance to make prudent investments and do not expect fiduciaries to duplicate their advisers’ investigative efforts, we believe that ERISA’s duty to investigate requires fiduciaries to review the data a consultant gathers, to assess its significance and to supplement it where necessary.”

• Best Pharmacy Benefit Consultants for Cost-Effective Drug Plans. In the complex world of healthcare and pharmaceuticals, managing costs while ensuring the best possible care can be a daunting challenge for businesses of all sizes. Pharmacy Benefit Consultants (PBCs) play a crucial role in navigating this landscape, offering expertise that can lead to significant savings and more effective drug plan management. This article delves into the importance of PBCs, what to look for when selecting a consultant, and how they can transform the cost-effectiveness of drug plans.

• 5 ways to improve your PBM procurement process in 2024. Many self-funded plan sponsors struggle to manage the cost of pharmacy benefits and rely on non-transparent contract guarantees to hold PBMs accountable. Meanwhile, drug spending continues to compound at an astonishing rate in defiance of the savings promised during the procurement process. As a former pharmacy program director for a plan covering more than 16,000 lives, I can tell you that it is possible to stop the “games” PBMs play, control costs, and ensure that all contractual guarantees are met, especially in scenarios where a PBM won’t guarantee an all-in per member per month (PMPM) cost for the year. Understanding the problem is a part of the solution, but making meaningful changes to the way plan sponsors and brokers evaluate PBMs is where the real opportunity lies.

• 3 thing to know about specialty pharmacy in 2024. Specialty drugs may be covered by a medical benefit (what patient-members likely think of as “their insurance”) or pharmacy benefits. There’s often a gray area for where specialty falls, but it can relate to whether the drug is being administered in a clinical setting, like a doctor’s office, outpatient clinic, or infusion center. Reimbursement for these drugs can also vary between average wholesale price (AWP) for pharmacy reimbursement and average sales price (ASP) for the medical benefit. It’s complex to compare, and both ASP and AWP are used in the health care industry, but they’re different. ASP is a government-regulated tool that uses manufacturer sales information including discounts, such as rebates. AWP is the average price that wholesalers sell drugs to pharmacies, prescribers, and others. A government report found the median percentage difference between ASP and AWP to be 49%.