Six Pillars of a High-Performing Pharmacy Benefit Plan Design
Non-fiduciary PBMs negotiate with drugmakers and pharmacies to benefit themselves. They use the purchasing power of plan sponsors who lack full insight into pharmacy economics. What used to be a cost-efficiency business is now, in many cases, about promoting the most profitable products, not the most clinically appropriate ones. If you're a smart buyer of PBM services, you want more control over your pharmacy benefit plan, not less. Here are six pillars of a high-performing pharmacy benefit plan design to help you build a plan that works in your favor. 1. Internal Expertise Internal expertise means a buyer or consultant has the knowledge to independently evaluate PBM contracts, pricing, and performance without relying on the PBM for direction. It includes deep knowledge of formularies, rebate structures, MAC pricing, and plan design strategies, for instance. Before partnering with a PBM or consultant, it’s worth asking a few key questions as a team: Do we have the pharmacy benefits expertise we need in-house?If not, would targeted education or outside support add value?Are the consultants we're relying on certified in pharmacy benefit management? As a Benefits Director, you don’t need to be a pharmacist, but you do need a strong understanding of how pharmacy benefits impact your plan's performance. Relying too heavily on a PBM or consultant without the right checks can expose your organization to unnecessary risk. That’s where Certified Pharmacy Benefits Specialists (CPBS) come in. Having credentialed support on your side gives you the clarity and leverage to keep your plan aligned with your goals, not someone else’s bottom line. 2. Access The formulary is your plan’s rulebook for drug access. It informs which medications are covered, at what cost to members, and under what conditions, guiding both prescribers and patients toward clinically appropriate and cost-effective choices. You should review formulary design regularly, especially for high-cost drug classes like GLP-1s used for weight loss. These drugs now exceed $1,000 per member per month. While effective, ICER has stated their prices are not justified by the long-term benefit in obesity treatment alone. PBMs may promote these drugs heavily due to large rebates. That’s not fiduciary. Make decisions based on outcomes and cost-effectiveness, not marketing hype or rebate flow. When managed by a fiduciary PBM, the formulary is designed to serve the plan sponsor’s best interest, not the PBM’s bottom line. 3. Medication Adherence Medication adherence refers to the extent to which a patient takes their medications as prescribed by their healthcare provider. This includes the correct dose, timing, frequency, and duration of use. Non-adherence drives over $290 billion in avoidable healthcare costs each year. Even the best-designed plan fails if members don’t take their medications. Use Proportion of Days Covered (PDC) to track adherence. A PDC of 80 percent or higher signals a member is staying on therapy. Monitor this at the plan level and intervene where necessary. Otherwise, avoidable ER visits and hospitalizations will drive up your total spend. 4. Cost Containment Cost containment in pharmacy benefits management refers to a…