As healthcare costs continue to rise, a notable shift is occurring: Employees are challenging these increases with unprecedented vigor. Armed with a growing awareness of their rights and the potential for more equitable solutions, workers are pushing back against what they see as irresponsible benefit practices.
This movement is gaining momentum in the wake of landmark litigation, including the recent class-action
This evolving dynamic places employers in a critical position and offers their advisers an opportunity to help guide them through this process. They are now tasked with navigating the complex interplay between meeting regulatory standards, managing costs and addressing their employees' demands for fair and transparent healthcare pricing. The challenge is significant, yet it lays the groundwork for fostering a more transparent, equitable healthcare system that benefits all stakeholders.
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It's important to note that the journey toward CAA compliance extends beyond the measures listed here. However, this strategic checklist provides a solid foundation for employers eager to align their practices with the principles of responsibility and prudence in their healthcare benefits management efforts.
1. Conduct annual market checks. It's essential to
2. Secure the best possible PBM contract. Managing PBM contracts requires a sophisticated understanding of the market. Employers should consider working with an independent partner capable of negotiating the best terms. A key consideration is whether your client's PBM accommodates third-party cost-containment solutions for specialty generics, which can significantly reduce member costs. Additionally, it's worth investigating if the PBM provides
3. Rigorous auditing of rebates. A critical component of managing PBM contracts is to confirm that an organization actually receives the rebates it has been promised. Regular audits can uncover discrepancies and ensure that rebates are accurately reflected and applied to offset premiums. This vigilance helps maintain financial integrity and ensures members benefit from the best possible terms.
4. Formulary management. The choice of formulary, especially in the context of biosimilars vs. higher-cost alternatives like Humira, can significantly impact cost savings. Employers should scrutinize their PBM's formulary choices, prioritizing those that favor cost-effective biosimilars without compromising on quality. Understanding the range of biosimilars offered is essential for informed decision-making.
5. Specialty generics discount guarantees. Specialty generics should be treated with a separate discount guarantee than specialty brands. Historically, PBMs have bundled these together, providing a general discount that doesn't necessarily favor the lower-cost generics. Employers should advocate for specific discount guarantees for generics to ensure these savings are passed down effectively.
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As employers navigate the complexities of pharmacy benefits management, staying informed and proactive is crucial. Implementing this checklist can help employer groups ensure they are not only compliant with the CAA but are also taking definitive steps toward optimizing their pharmacy benefits in a way that balances cost with quality care. In doing so, they can protect their interests and those of their members, setting a standard for responsible and effective healthcare benefits management.
