The Employer's Guide Blog for Overseeing PBMs

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Physician Practices Must Create a System to Deal with PBM Drug Denials

In today’s pharmacy benefit management environment, it is costing practices more staff time and money to simply get the right drugs to their patient, but the alternative is an angry, unhappy patient. “Staff working with PBMs must be advocates for your patients,” said Patti Barkey, COE, chief executive officer of Bowden Eye and Associates.

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“This is one of the areas where there are a lot of things that are out of our control but at the end of the day, the patient experience is very much expected to be in our control by the patient.” She warned of this scenario: A patient is given a prescription, goes to the pharmacy to pick it up and is told they can’t have it, without ever having been told that could happen.

Tyrone’s Commentary:

Amen! Finally, a physician on record not pointing the finger and accepting some accountability. That being said, PBMs too must continue to work on making the process of filling prescriptions more efficient and transparent. Employers and brokers alike should also recognize that with rising drug costs, formularies become more restrictive to offset those rising costs. 

A tightly managed formulary doesn’t mean it is less effective, necessarily. In fact, the opposite is usually true. Employees achieve similar outcomes at lower costs with tightly managed formularies. If a tablet form is significantly less expensive than a capsule, the tablet is covered while the capsule is not, for instance.

She encouraged attendees to create systems and processes to streamline addressing drug denials, prior authorizations and the review of alternatives. “We have to create systems in our organizations to better understand this process,” she said.

“If you look at the struggles taking place, … we can’t get the right prescriptions to the patients a lot of the time. New drugs are coming out and new things are getting approved, and we know the patients need them. My senior physician likes to say the prescribing of drug is just a suggestion these days – it is not an order.”

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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.

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