FTC second interim staff report finds PBMs charge significant markups and other notes from around the interweb:

• FTC Second Interim Staff Report Finds PBMs Charge Significant Markups. The Federal Trade Commission today published a second interim staff report on the prescription drug middleman industry, which focuses on pharmacy benefit managers’ (PBMs) influence over specialty generic drugs, including significant price markups by PBMs for cancer, HIV, and a variety of other critical drugs. Staff’s latest report found that the ‘Big 3 PBMs’—Caremark Rx, LLC (CVS), Express Scripts, Inc. (ESI), and OptumRx, Inc. (OptumRx)—marked up numerous specialty generic drugs dispensed at their affiliated pharmacies by thousands of percent, and many others by hundreds of percent. Such significant markups allowed the Big 3 PBMs and their affiliated specialty pharmacies to generate more than $7.3 billion in revenue from dispensing drugs in excess of the drugs’ estimated acquisition costs from 2017-2022.

• Medicare Coverage of Anti-Obesity Medications? The proposed reinterpretation of Medicare Part D coverage of anti-obesity medications may provide approximately 3.4 million Medicare beneficiaries who have obesity with access to these innovative therapies. Medicare coverage would reduce out-of-pocket costs for these prescription drugs by as much as 95 percent for some enrollees. Approximately four million adult Medicaid enrollees may also gain new access to these medications.

• Pharmacy Benefit Manager uses unallowable pricing model. Spread pricing occurs when a managed care organization (MCO) reimburses its pharmacy benefit manager (PBM) for a prescription at a higher rate than what the PBM pays the pharmacy. This discrepancy, representing the prescription cost, is prohibited under Medicaid rules. Medicaid mandates that MCOs reimburse PBMs only for the actual prescription cost while also paying a separate administrative fee to the PBM for managing the program.

• How a Duty To Spend Wisely on Worker Benefits Could Loosen PBMs’ Grip on Drug Prices. Ann Lewandowski knows all about pharmacy benefit managers, or PBMs, the companies that shape the U.S. drug market. Her job, as a policy advocate at drugmaker Johnson & Johnson, was to tell patient and physician groups about the PBMs’ role in high drug prices. Armed with that knowledge, Lewandowski filed a potentially groundbreaking lawsuit in February. Rather than targeting the PBMs, however, she went after a big company that uses one — her own employer, Johnson & Johnson. Lewandowski charges in her lawsuit that by contracting with the PBM Express Scripts, which is part of the insurance giant Cigna, Johnson & Johnson — which fired her in April — failed in its duty to ensure reasonable drug prices for its more than 50,000 U.S. employees.

Why TransparentRx Is Your Trusted Partner for Smarter Pharmacy Benefits

At TransparentRx, we specialize in delivering fiduciary pharmacy benefit management services that prioritize transparency, cost containment, and optimal patient outcomes. Our unique approach helps self-funded employers, benefits consultants, and health plan sponsors navigate the complexities of pharmacy benefits while reducing costs and enhancing care.

If you’re ready to take control of your pharmacy benefit strategy and eliminate hidden fees, contact TransparentRx today for a consultation. Let us help you achieve smarter, more effective benefits management.

Negotiating a pharmacy benefit manager (PBM) contract is a pivotal step for self-insured employers looking to reduce costs, improve transparency, and deliver better outcomes for their employees. However, success in these negotiations requires strategy, preparation, and collaboration across the organization. Below are six key steps on how self-insured employers can optimize PBM contract negotiations to ensure optimal results.

1. Start Negotiating One Year in Advance

Effective PBM contract negotiations require ample time for due diligence, analysis, and back-and-forth discussions. Initiating negotiations at least a year before your existing contract’s renewal allows room to:

• Review and assess the current PBM’s performance.
• Compare options with other providers.
• Address potential roadblocks without the pressure of looming deadlines.

Starting early also signals to PBMs that you are serious about understanding and refining your pharmacy benefit offerings. It shifts the balance of power by giving you time to walk away if terms don’t align with your goals.

2. Support Contract Proposals and Requests with Data

PBMs thrive on complexity, and data can be your most powerful tool to level the playing field. Leverage claims data, cost trend analyses, and utilization reports to justify your requests during negotiations. For example:

• Use data to highlight inefficiencies or hidden fees in your current arrangement.
• Model the financial impact of potential contract changes.
• Benchmark performance metrics against industry standards.

Solid data transforms your arguments from subjective preferences into objective requirements, increasing the likelihood of favorable terms.

3. Make It About More Than Just Price

Focusing too much on price (i.e., discounts, rebates, NADAC etc.) leaves value on the table. Instead, negotiate for terms that provide holistic cost management and improve employee outcomes. Consider provisions such as:

• Radically transparent pricing models that eliminate spread pricing or rebate gaming.
• Clinical programs that promote adherence, optimize therapy, and reduce waste.
• Non-exclusivity rights, such as specialty or mail pharmacy, to ensure control and flexibility.

A price-centric approach might save money in the short term but fail to address long-term value or alignment with your goals as a self-insured employer.

4. Partner with Experts

PBM negotiations are highly technical, and partnering with certified experts can give you an edge. Certified Pharmacy Benefits Specialists (CPBS) bring a deep understanding of the PBM industry’s profit models, contract structures, and cost-containment opportunities. Their expertise ensures you avoid pitfalls like hidden fees, misaligned incentives, and vague terms.

Benefits of working with CPBS professionals include:

• Enhanced Negotiation Strategies: CPBS-certified consultants identify and prioritize areas where you can achieve significant cost savings without sacrificing patient outcomes.
• Comprehensive Market Insights: They bring a detailed understanding of industry benchmarks and emerging trends, ensuring you’re equipped with the most up-to-date strategies.
• Comprehensive Audit Support: Experts ensure your PBM adheres to the agreed-upon contract terms, reducing waste and uncovering potential savings.

There is often a disconnect between what self-insured employers assume their consultants understand about pharmacy benefits and the consultants’ actual level of expertise. A CPBS-certified consultant closes the gap by acting as your advocate, providing the knowledge and confidence to negotiate contracts that truly align with your goals.

5. Understand Your Leverage

Your ability to secure favorable terms depends on understanding your leverage. Factors such as employee population size, claims volume, and the competitiveness of your local PBM market play a significant role. Key ways to enhance leverage include:

• Highlighting your readiness to switch to a more favorable PBM.
• Demonstrating your knowledge of the PBM’s cost drivers and profit models.
• Partnering with a fiduciary-model PBM that prioritizes your interests.

When you understand where you hold power, you can negotiate from a position of strength rather than dependency.

6. Ensure Strategic Alignment Among Executive Leaders

PBM negotiations shouldn’t be conducted in silos. Cross-functional alignment among finance, HR, and executive leadership ensures consistency in goals and priorities. Develop a unified strategy that clearly outlines:

• The organization’s priorities (e.g., cost savings, improved outcomes, or transparency).
• Non-negotiable contract terms.
• How pharmacy benefit changes align with broader benefits strategies.

When leadership is aligned, negotiations are more focused and decisive, reducing the likelihood of costly delays or internal disagreements.

Final Thoughts

Optimizing PBM contract negotiations is about more than securing the lowest price; it’s about creating a partnership that drives better outcomes for both your organization and its employees. By starting early, leveraging data, focusing on long-term value, and ensuring alignment across stakeholders, self-insured employers can significantly improve their position and secure terms that align with their objectives.

To learn more about how to approach PBM contract negotiations with a fiduciary mindset, visit TransparentRx.

Medicare Coverage of Anti-Obesity Medications and other notes from around the interweb:

• Medicare Coverage of Anti-Obesity Medications? The proposed reinterpretation of Medicare Part D coverage of anti-obesity medications may provide approximately 3.4 million Medicare beneficiaries who have obesity with access to these innovative therapies. Medicare coverage would reduce out-of-pocket costs for these prescription drugs by as much as 95 percent for some enrollees. Approximately four million adult Medicaid enrollees may also gain new access to these medications.

• Pharmacy Benefit Manager uses unallowable pricing model. Spread pricing occurs when a managed care organization (MCO) reimburses its pharmacy benefit manager (PBM) for a prescription at a higher rate than what the PBM pays the pharmacy. This discrepancy, representing the prescription cost, is prohibited under Medicaid rules. Medicaid mandates that MCOs reimburse PBMs only for the actual prescription cost while also paying a separate administrative fee to the PBM for managing the program.

• Ex-McKinsey partner pleads guilty to destroying records about work promoting opioids. The case followed years of investigations and litigation concerning the extent to which Purdue and other drugmakers contributed to a deadly opioid addiction epidemic in the U.S. The U.S. Centers for Disease Control and Prevention says nearly 727,000 opioid overdose deaths occurred from 1999 to 2022. Purdue is currently involved in court-ordered mediation to rework a multibillion-dollar civil settlement with states, local governments and others in bankruptcy proceedings after the U.S. Supreme Court “turned aside” its initial deal.

• How a Duty To Spend Wisely on Worker Benefits Could Loosen PBMs’ Grip on Drug Prices. Ann Lewandowski knows all about pharmacy benefit managers, or PBMs, the companies that shape the U.S. drug market. Her job, as a policy advocate at drugmaker Johnson & Johnson, was to tell patient and physician groups about the PBMs’ role in high drug prices. Armed with that knowledge, Lewandowski filed a potentially groundbreaking lawsuit in February. Rather than targeting the PBMs, however, she went after a big company that uses one — her own employer, Johnson & Johnson. Lewandowski charges in her lawsuit that by contracting with the PBM Express Scripts, which is part of the insurance giant Cigna, Johnson & Johnson — which fired her in April — failed in its duty to ensure reasonable drug prices for its more than 50,000 U.S. employees.

Why TransparentRx Is Your Trusted Partner for Smarter Pharmacy Benefits

At TransparentRx, we specialize in delivering fiduciary pharmacy benefit management services that prioritize transparency, cost containment, and optimal patient outcomes. Our unique approach helps self-funded employers, benefits consultants, and health plan sponsors navigate the complexities of pharmacy benefits while reducing costs and enhancing care.

If you’re ready to take control of your pharmacy benefit strategy and eliminate hidden fees, contact TransparentRx today for a consultation. Let us help you achieve smarter, more effective benefits management.

Fiduciary duty ensures trust and accountability between PBMs and clients in the complex world of pharmacy benefit management. Understanding PBM fiduciary duty helps benefits directors, brokers, and CFOs align PBM agreements with organizational goals while protecting plan members’ interests.

What Is Fiduciary Duty?

Fiduciary duty requires a PBM to act in the best interests of its clients—self-insured employers, health plans, or unions. This duty extends beyond standard business obligations, encompassing care, skill, prudence, and diligence comparable to a similar enterprise with aligned objectives. Fiduciary responsibility ensures transparency and mitigates conflicts of interest that could compromise the client’s financial or operational integrity.

Core Components of PBM Fiduciary Duty

• Standard of Care PBMs like TransparentRx agree to operate with a high standard of care, skill, and prudence. This means managing the pharmacy benefit program with the same diligence as a fiduciary in a comparable role, safeguarding the client’s and covered individuals’ interests.
• Conflict of Interest Disclosure Fiduciary PBMs must notify clients of any activity or policy that creates a direct or indirect conflict of interest. For instance, if a PBM profits from recommending a higher-cost drug instead of a lower-cost alternative, it must disclose such arrangements.
• Transparent Financial Reporting PBMs must provide clients with detailed financial and utilization data. This includes information on drug costs, rebates, and any payments received from pharmaceutical manufacturers. Transparency empowers clients to verify that plan dollars are being utilized effectively and ethically.
• Drug Substitution Transparency PBMs must disclose cost details and benefits gained from substituting one prescription drug for another. If a substitution increases costs or generates a financial benefit for the PBM, they must pass those benefits entirely to the client.
• Pass-Through Rebates and Payments Fiduciary PBMs ensure that any payments or benefits received from drug manufacturers, based on sales volume or other incentives, are transferred directly to the client. This practice prevents misaligned incentives that could otherwise drive up plan costs.
• Disclosure of Financial Arrangements PBMs must disclose financial arrangements with pharmaceutical manufacturers or other stakeholders, such as formulary management fees, educational support, or data sales fees, to the client. To ensure full transparency while protecting proprietary information, clients may need to sign confidentiality agreements.

Legal Recourse for Breaches of Fiduciary Duty

Clients can seek legal remedies, like injunctive relief or damages, if a PBM violates its fiduciary duty. Courts may award attorney’s fees and costs to prevailing clients, helping organizations hold PBMs accountable without excessive financial strain.

Why Fiduciary PBMs Are the Future

Fiduciary PBMs like TransparentRx are reshaping the pharmacy benefits landscape by prioritizing transparency, accountability, and client outcomes. For employers and plan sponsors, partnering with a fiduciary PBM translates into measurable cost savings, ethical practices, and improved plan member satisfaction. Fiduciary duty is not just a legal term—it’s a commitment to doing what’s right.

Conclusion

Understanding PBM fiduciary duty equips benefits professionals and organizational leaders with the knowledge to demand transparency and accountability. By aligning with fiduciary PBMs, organizations can ensure that every dollar spent on pharmacy benefits works toward the health and well-being of their covered individuals, rather than fueling unnecessary profit margins.

Choosing a fiduciary PBM isn’t just a strategic decision—it’s a responsibility to your organization and its members.

Drugmakers to hike US prices of over 250 branded medications and other notes from around the interweb:

• Drugmakers to hike US prices of over 250 branded medications. Drugmakers plan to raise the prices of at least 250 branded medications in the US at the start of 2025, per data analyzed by 3 Axis Advisors and reported on by Reuters. The increases are to list prices and do not include discounts or rebates to pharmacy benefit managers (PBMs). The median price increase of the drugs is 4.5%, which is consistent with the median for all drug price increases in 2024. Just a decade ago, the median price increase for branded drugs was 9%. What’s driving this decision? While smaller than they used to be, the price hikes are an avenue for drugmakers to bolster their bottom lines.

• Utah sues pharmacy benefit managers, arguing they flooded the state with opioids. In a statement issued earlier this week, Executive Director of the Utah Department of Commerce Margaret Busse said pharmacy benefit managers played a “covert role” in the opioid crisis, which for several years has killed more than 100,000 Americans annually. Although rates appear to be in decline after hitting an unprecedented high of approximately 111,000 deaths in 2022, data suggests more than one hundred Americans still die each day from some kind of opioid. The complaint accuses the companies of colluding with manufacturers to give opioids “preferred status” as a prescription drug, while failing to use “the wealth of data” available that showed the dangers of overprescribing opioids. The state also alleges companies failed to comply with state and federal laws by “dispensing opioids through their mail order pharmacies.”

• How a Duty To Spend Wisely on Worker Benefits Could Loosen PBMs’ Grip on Drug Prices. Ann Lewandowski knows all about pharmacy benefit managers, or PBMs, the companies that shape the U.S. drug market. Her job, as a policy advocate at drugmaker Johnson & Johnson, was to tell patient and physician groups about the PBMs’ role in high drug prices. Armed with that knowledge, Lewandowski filed a potentially groundbreaking lawsuit in February. Rather than targeting the PBMs, however, she went after a big company that uses one — her own employer, Johnson & Johnson. Lewandowski charges in her lawsuit that by contracting with the PBM Express Scripts, which is part of the insurance giant Cigna, Johnson & Johnson — which fired her in April — failed in its duty to ensure reasonable drug prices for its more than 50,000 U.S. employees.

• PBMs facing increasing pressure: 4 things to know? Tucked into the bipartisan budget deal that President-elect Donald Trump’s allies torpedoed earlier this month was a rare and significant attempt to reform the mechanics of America’s drug-pricing system. While the PBM provisions in the 1,547-page stopgap bill are now dead, they are far from buried. The bipartisan agreement highlighted a growing consensus that PBM business models are flawed, with both Republicans and Democrats—and even Trump himself—signaling intent to take action. In recent weeks, Trump has twice criticized PBMs, declaring in a press conference his intention to “knock out the middleman.” At the core of the failed reform effort was a push for greater transparency and alignment in PBM operations. Among the proposed measures were requirements that PBMs disclose more data.

Why TransparentRx Is Your Trusted Partner for Smarter Pharmacy Benefits

At TransparentRx, we specialize in delivering fiduciary pharmacy benefit management services that prioritize transparency, cost containment, and optimal patient outcomes. Our unique approach helps self-funded employers, benefits consultants, and health plan sponsors navigate the complexities of pharmacy benefits while reducing costs and enhancing care.

If you’re ready to take control of your pharmacy benefit strategy and eliminate hidden fees, contact TransparentRx today for a consultation. Let us help you achieve smarter, more effective benefits management.

Pharmacy costs are one of the fastest-growing components of healthcare spending, yet they remain a mystery to many plan sponsors. If you’re an employee benefits consultant or a director of benefits, understanding the drivers of these costs is essential to protecting your plan’s financial health while ensuring members receive the care they need.

Let’s delve into the four key drivers of pharmacy costs and how you can take control:

1. Price: What Are You Really Paying?

Price is influenced by the list price of medications, inflation, and the terms negotiated with pharmacy benefit managers (PBMs). Contractual elements like rebates, fees, and discounts can either reduce costs or camouflage hidden markups. For example, PBMs might focus on maximizing rebates rather than minimizing your total drug spend, creating a misaligned incentive structure.

Action Step: Work with a fiduciary PBM to ensure your plan’s best interests come first. A fiduciary model PBM guarantees transparency and ensures cost-reducing strategies directly benefit your plan.

2. Product Mix: The Specialty Drug Dilemma

Specialty medications represent less than 2% of prescriptions but often consume over half of a pharmacy plan’s budget. Additionally, choosing between generics and brand-name drugs—or traditional versus specialty medications—dramatically affects overall costs.

For instance, an increase in the specialty dispensing rate from 1% to 3% can add a staggering $9.1 million to a $10 million annual plan spend. This underscores the importance of proactive management of your plan’s product mix.

Action Step: Adopt a value-based formulary that prioritizes clinically effective and cost-efficient medications. This approach can balance quality care with financial responsibility.

3. Utilization: The Impact of Volume

The frequency and duration of prescriptions, along with the channels through which they’re filled, directly affect your pharmacy spend. Key factors include:

• Number of utilizers: A growing number of plan members taking medications.
• Days’ supply: Long-term prescriptions, like 90-day supplies, may lower refill costs but increase upfront expenses.
• Channel mix: Choosing between retail, mail-order, or specialty pharmacies can significantly influence costs.

Action Step: Implement client-patient-first utilization management programs to ensure prescriptions are appropriate and cost-effective without disrupting care.

4. Cost Share: Influencing Consumer Behavior

Cost share—the portion of expenses covered by members through copays, coinsurance, and deductibles—can shape medication adherence and utilization patterns. A poorly designed cost-share structure might lead to higher downstream medical costs due to nonadherence.

Action Step: Design benefit structures that align cost-sharing with plan goals, ensuring members have access to necessary medications without excessive financial burden.

Your Path to Smarter Pharmacy Spend

Addressing these drivers doesn’t require compromising care quality. By focusing on transparency, informed decision-making, and strategic partnerships, you can significantly reduce costs while supporting positive outcomes.

At TransparentRx, we specialize in empowering plan sponsors with the tools and insights they need to succeed. Let us help you navigate these challenges with confidence.

Learn more about controlling pharmacy costs by partnering with TransparentRx. Visit transparentrx.com today.

How Accumulator Programs Exploit Patients and Drive-Up Medical Costs and other notes from around the interweb:

• How Accumulator Programs Exploit Patients and Drive Up Medical Costs. Accumulator programs collect the maximum amount of patient copay assistance at the start of a year, to exclude it from the patient’s annual cost-sharing limits. They target unsuspecting patients and send them hefty, unanticipated medical costs later in the plan year. A California woman with stage 4 lung cancer, the named plaintiff, sued after Blue Cross Blue Shield (BCBS) blocked her from accessing AstraZeneca’s co-pay assistance for Tagrisso, an expensive specialty medication. AstraZeneca provides co-pay assistance to commercially insured patients like her, but the lawsuit claims BCBS’s involvement in SaveOnSP deprived her of this benefit, forcing her to shoulder excessive healthcare expenses.

• Drugmakers paid pharmacy benefit managers to avoid restricting opioid prescriptions. There have been many entities accused of being the culprits of the spread of opioid abuse across the country during the last few years. One group had not been held accountable — until a recent New York Times investigation exposed how Big Pharma incentivized pharmacy benefit managers not to restrict painkiller prescriptions. This information has added a new layer of blame to a convoluted crisis. For years, pharmacy benefit managers “took payments from opioid manufacturers,” including Purdue Pharma, in return for “not restricting the flow of pills,” The New York Times said in its exposé. As tens of thousands of Americans succumbed to overdoses and the opioid crisis raged on, “the middlemen collected billions of dollars in payments.” The benefit managers “exert extraordinary control over what drugs people can receive and at what price,” the Times said.

• How a Duty To Spend Wisely on Worker Benefits Could Loosen PBMs’ Grip on Drug Prices. Ann Lewandowski knows all about pharmacy benefit managers, or PBMs, the companies that shape the U.S. drug market. Her job, as a policy advocate at drugmaker Johnson & Johnson, was to tell patient and physician groups about the PBMs’ role in high drug prices. Armed with that knowledge, Lewandowski filed a potentially groundbreaking lawsuit in February. Rather than targeting the PBMs, however, she went after a big company that uses one — her own employer, Johnson & Johnson. Lewandowski charges in her lawsuit that by contracting with the PBM Express Scripts, which is part of the insurance giant Cigna, Johnson & Johnson — which fired her in April — failed in its duty to ensure reasonable drug prices for its more than 50,000 U.S. employees.

• 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.

Why TransparentRx Is Your Trusted Partner for Smarter Pharmacy Benefits

At TransparentRx, we specialize in delivering fiduciary pharmacy benefit management services that prioritize transparency, cost containment, and optimal patient outcomes. Our unique approach helps self-funded employers, benefits consultants, and health plan sponsors navigate the complexities of pharmacy benefits while reducing costs and enhancing care.

If you’re ready to take control of your pharmacy benefit strategy and eliminate hidden fees, contact TransparentRx today for a consultation. Let us help you achieve smarter, more effective benefits management.

Many plan sponsors discover too late that one of the biggest drivers of their pharmacy spending isn’t the price of the drugs themselves. It’s the hidden margin between what the PBM bills to the plan and what it pays the pharmacy, known as spread pricing. The trouble starts in the RFP process, where cost comparisons often appear clean and straightforward on paper. In reality, three challenges make it difficult to pinpoint true costs thus the real problem with PBM spread pricing.

1. Opaque Language
   A Director of Benefits once confided that her initial pricing proposal seemed too good to be true. The PBM’s bid boasted impressive discount guarantees, but the contract’s language was vague on how those savings would be passed through. Later, she learned that pharmacy claims were paid at a lower rate than what the plan was billed, with the PBM pocketing the difference.

2. Focus on Discounts or Price Benchmarks Over Net Cost
   A CFO reviewing multiple PBM bids noticed they focused on discount guarantees: “AWP minus X%” for brands and “MAC price” for generics. The spreadsheets looked competitive, but he never found a clear statement of net costs. Months into the contract, the weekly invoices revealed that true costs for high-volume generics kept creeping up. The CFO realized that the “savings” factored into the spreadsheets didn’t show how spreads were adding to the final bill.

3. Contract Complexity
   One employee benefits consultant described a convoluted 40-page PBM agreement where terms like “House Generics” and “Brand Base Guarantee” were buried. This made it tough to reconcile how much the PBM paid pharmacies with what the plan owed. By the time they uncovered discrepancies, it was clear the spread fees were much higher than expected.

How to Address PBM Spread Pricing Challenges

• Insist on Pass-Through Pricing
  Require that all negotiated rates, including post-adjudication, flow directly to your plan. If a PBM pays a pharmacy $10 for a claim, your plan pays the same $10, not $100. Ask that every RFP explicitly confirms whether the PBM guarantees this standard.

• Continuously Monitor Claims and Terms
  Check whether the PBM’s invoiced claim file aligns with what the pharmacy actually received. Audits don’t have to be a headache when conducted regularly or paired with automation. If something doesn’t match the agreement, bring it up immediately.

• Work with a Fiduciary PBM
  A fiduciary PBM won’t profit from spread or undisclosed fees. The PBM’s commitment ensures that you see the true cost of each prescription. The fiduciary model also builds trust and transparency, so you can accurately plan and manage costs without worrying about hidden margins.

It’s possible to stop paying for spreads you didn’t sign up for. Clarity in contracts, regular checks on performance, and partnering with a PBM that truly aligns with your goals can remove the guesswork and give you more control over your pharmacy benefits.

How a Duty to Spend Wisely on Worker Benefits Could Loosen PBMs’ Grip on Drug Prices and other notes from around the interweb:

• How a Duty To Spend Wisely on Worker Benefits Could Loosen PBMs’ Grip on Drug Prices. Ann Lewandowski knows all about pharmacy benefit managers, or PBMs, the companies that shape the U.S. drug market. Her job, as a policy advocate at drugmaker Johnson & Johnson, was to tell patient and physician groups about the PBMs’ role in high drug prices. Armed with that knowledge, Lewandowski filed a potentially groundbreaking lawsuit in February. Rather than targeting the PBMs, however, she went after a big company that uses one — her own employer, Johnson & Johnson. Lewandowski charges in her lawsuit that by contracting with the PBM Express Scripts, which is part of the insurance giant Cigna, Johnson & Johnson — which fired her in April — failed in its duty to ensure reasonable drug prices for its more than 50,000 U.S. employees.

• Drugmakers paid pharmacy benefit managers to avoid restricting opioid prescriptions. There have been many entities accused of being the culprits of the spread of opioid abuse across the country during the last few years. One group had not been held accountable — until a recent New York Times investigation exposed how Big Pharma incentivized pharmacy benefit managers not to restrict painkiller prescriptions. This information has added a new layer of blame to a convoluted crisis. For years, pharmacy benefit managers “took payments from opioid manufacturers,” including Purdue Pharma, in return for “not restricting the flow of pills,” The New York Times said in its exposé. As tens of thousands of Americans succumbed to overdoses and the opioid crisis raged on, “the middlemen collected billions of dollars in payments.” The benefit managers “exert extraordinary control over what drugs people can receive and at what price,” the Times said.

• Zepbound Approved for Obstructive Sleep Apnea. The U.S. Food and Drug Administration on Friday approved Eli Lilly’s (LLY.N), opens new tab weight-loss treatment, Zepbound, for obstructive sleep apnea, making it the first drug greenlighted to directly treat patients with the common sleeping disorder. The regulator approved the drug for moderate to severe obstructive sleep apnea in adults with obesity, the company said. The approval opens up a wide market of patients for Lilly at a time when demand for Zepbound is already surging. It could also strengthen Lilly’s case with commercial insurers and employers, who have previously hesitated to cover the drug due to its high cost. Shares of the Indianapolis-based drugmaker were up 1.14% in after-market trading following the announcement. Sleep apnea patients stop breathing briefly while sleeping, disturbing the sleep cycle and causing long-term complications such as heart conditions. The condition affects roughly one billion people globally.

• 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.

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.