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.

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, including specialty drug coverage, benefit design, and wellness integration, leading to improved health outcomes and cost savings.

Conclusion

In an era where healthcare costs continue to rise, and the landscape of pharmacy benefits grows increasingly complex, the value of Certified Pharmacy Benefits Specialists (CPBS) cannot be overstated. By relying on certified professionals, unions, health plans, health systems, and employers can mitigate the risks associated with self-professed experts. Certification ensures that these critical stakeholders have access to knowledgeable, accountable, and ethical experts who are committed to optimizing pharmacy benefits in the best interest of their clients. The Certified Pharmacy Benefits Specialist (CPBS) program stands at the forefront of this effort, providing a benchmark for excellence and integrity in the field of pharmacy benefits management.