Managing and containing pharmacy drug costs is complex. As the industry evolves and parties demand more transparency into a traditionally obscure system, having a trusted pharmacy benefit manager (PBM) can give you confidence that your investment is being managed properly. Evaluate your existing PBM partnership by asking these eight questions.
A pass-through pricing model is ideal because it aligns the interest of the PBM with your interest, however pass-through doesn’t necessarily mean transparent. In fact, some traditional pricing models are more transparent than pass through if all revenue streams are disclosed. Many PBMs will generate revenue directly or indirectly from your claims and you have the right to understand where and how much the PBM is making through the administration of your program.
Of equal importance to the pricing structure are the pricing terms. Complex formulas to determine the definition of a generic drug should be eliminated. The determination of a generic drug should come from an outside source such as Medispan. Guarantees on a pass-through model should be minimum guarantees. Finally, a guarantee should only be calculated based on claims processed at the contracted rate.
It’s important to know how each party will be compensated. Demand transparency beyond a pass-through arrangement by understanding revenue breakdowns over the entire life of the contract.
PBM ownership of specialty or mail-order pharmacies can create a significant conflict of interest. If your PBM vendor owns a pharmacy that will benefit financially from filling a medication, they should not be in the position to determine who receives the medication. If this is not possible, have your PBM supply you with a monthly approval and denial report that shows activity for medications requiring prior authorization.
Related resource: How to Evaluate your Pharmacy Benefit Management Pricing Arrangement
Distinguish formulary management that promotes brand medications from generic incentive programs. For example, step therapy should never steer towards more expensive brand-name medications. Only implement utilization programs that promote cost-effective generics.
Contracts based on a discount off AWP typically result in huge revenues for the PBM that only increase as specialty drug costs rise. Seek acquisition based pricing for specialty claims during your vendor evaluation process.
Many mail order pharmacies claim large discounts and better adherence rates. In reality, the discounts are negated by misaligned copays and auto-refill programs contribute to stockpiling and filling unnecessary orders. A 90-day retail maintenance network eliminates these concerns and maintains the critical pharmacist/patient relationship.
With true transparent pricing, costs to your plan and your employees can vary from pharmacy to pharmacy, it’s important to educate employees on highest-value options. Grocery and discount stores like Walmart and Costco are generally less expensive than the big chain drug stores.