The Employer's Guide Blog for Overseeing PBMs

The Definition of Oversee: to watch over and direct (an undertaking, a group of workers, etc.) in order to ensure a satisfactory outcome or performance.

Don’t look now but things are getting even more complicated: Point-of-sale discounts (rebates) to consumers as part of employer-sponsored plan design

Building on the introduction of its point-of-sale (POS) discount program, OptumRx and UnitedHealthcare are expanding their POS prescription drug discount programs to apply to all new employer-sponsored plans. The idea behind the expansion is to make medications more affordable and to improve health outcomes.

Tyrone’s Commentary:

Education is the leading market driver of transparency
in the PBM space. Employers click here to learn more.

1) The POS discount program alone doesn’t change the rebate share Optum keeps for itself which is the biggest problem. Optum’s POS rebates may reallocate part of the plan sponsor’s share to another participant (patient) in the US Pharmacy Reimbursement and Distribution System, for example.

2) Patients should be able to benefit from lower costs so I agree with the premise. However, how is the POS rebate calculated and is it consistent? A patient with a 20% coinsurance should receive a larger rebate than a patient with a lower flat copay especially when that flat copay is significantly lower than the OOP for coinsurance. POS discounts or rebates can make the process of getting to true cost or eliminating overpayments challenging to say the least.

3) Reporting. This adds another layer which OptumRx or any non-fiduciary PBM could make it difficult for the plan sponsor to ascertain the patient’s financial benefit, at the POS, which can lead to an increase of opacity.

Bottom line plan sponsors now more than ever need to win radical transparency from their PBM. Now that one additional beneficiary [patient] has been added to the financial flow of money, from rebates, the US Pharmacy Reimbursement and Distribution System is even more complicated.

[Read More]

Tyrone Squires, MBA, CPBS

I am the proud founder and managing director of TransparentRx, a fiduciary-model PBM based in Las Vegas, Nevada. We help health plan sponsors reduce pharmacy spend, by as much as 50%, without cutting benefits or shifting costs to employees.

Leave a Reply