In today's rapidly evolving healthcare landscape, managing pharmacy benefits is not just about containing costs—it's about crafting a synergy of quality care, accessibility, efficiency, and participant satisfaction. At TransparentRx, we understand that every aspect of pharmacy benefit design can significantly impact the health and well-being of the participants it serves. Let's delve into the four broad issues that underpin an effective pharmacy benefit design. 1. Quality: The Pillar of Care Quality in pharmacy benefits is threefold: care structure, processes, and outcomes. A robust care structure is foundational, ensuring that participants have access to essential medications without unnecessary delays or hurdles. The process, from prescription to pill delivery, must be streamlined, clear, and consistently monitored for potential improvements. Outcomes are the ultimate measure of quality. At TransparentRx, we prioritize the clinical effectiveness of the medications provided and the positive health outcomes for the participant. This includes not only the resolution of the condition being treated but also monitoring for potential drug abuse, interactions, and side effects. 2. Accessibility: Removing Barriers Accessibility goes beyond the physical availability of medications. It encompasses the elimination of financial, transportation, and geographical barriers that participants may face. TransparentRx champions affordable options without sacrificing quality. Whether it's negotiating better prices or embracing mail-order services, we ensure that medications are within reach, both geographically and financially. Transportation and geographical challenges are addressed by a network of pharmacies and the use of innovative delivery methods. By enhancing our telehealth and mail-order services, we bring the pharmacy to the participant's doorstep, no matter where they live. Understanding the distinctions between effective and ineffective benefit design practices is crucial. Below, we present a table contrasting strong (good) examples of benefit design with practices that should be avoided (bad) for each of the four broad issues: Comparative Analysis: Click Here to Learn More By recognizing the stark contrast between these examples, employers, brokers, and consultants can more effectively evaluate and select pharmacy benefit plans that align with the fiduciary standard of care and participant-centric values. TransparentRx stands ready to guide you through the intricacies of these issues, ensuring that your pharmacy benefit design is both cost-effective and highly beneficial to your participants. 3. Efficiency: Maximizing Resources Efficiency in pharmacy benefit design means accomplishing plan objectives with the least expensive combination of resources—without compromising on quality. At TransparentRx, we leverage InsourceRx data analytics to understand usage patterns, eliminate waste, and prevent fraud. We assess the therapeutic equivalents and generic options, ensuring the most cost-effective medications are available. By balancing the cost against clinical effectiveness, we provide a plan that respects both the participant's health and the bottom line. 4. Participant Satisfaction: The Heart of Our Mission The true measure of a successful pharmacy benefit design is participant satisfaction. It reflects the ease of using the plan, the quality of the interactions with pharmacy staff, and the clarity of information provided. TransparentRx takes pride in our Net Promoter Score (NPS) of 86, which is a testament to our commitment to participant satisfaction. This score…

Reviewing PBM Alternative Pricing Models for CVS Health, ESI, and OptumRx and other notes from around the interweb: Stand Out Among PBM Consultants and Pharmacists 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…

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. Table Summary of Pharmacy Benefit Cost Drivers 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,…

Mayo Clinic employee files class action lawsuit over high health care costs and other notes from around the interweb: Stand Out Among PBM Consultants and Pharmacists 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. Stand out among PBM Consultants and PBM Pharmacists 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: Stand Out Among PBM Consultants and Pharmacists 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: MTM Process Workflow 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.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.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.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.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.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: Become an Expert in Managing Pharmacy Benefits 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…

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. Click Here to Zoom In 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,…