The pharmacy benefit management (PBM) ecosystem is deeply broken. Not only does the current system lead to
Self-insured employers, advisors and benefits brokers all have
But nothing will change until
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Consider these questions:
Is your PBM transparent?
Look for the sentence in the contract that says, "We will charge what we pay the pharmacy." Without that explicit promise, employers can fall victim to spread pricing, hidden rebate fees and high-cost formularies.
What level of service do you provide as a PBM?
Does a PBM take a proactive approach to provide service? When your employees need help, does a live human being answer the phone? Or do employee calls get stuck in a web of automated prompts? Personalized care and service really do matter.
How involved are clinical pharmacists?
Clinical pharmacists should always be involved in pharmacy benefit plan design and reviews. Without the direct involvement and valued input of a clinical pharmacist, you'll be unable to understand the impact of formulary options, nor will you have insight into industry changes and upcoming drug approvals that may affect your plan.
What type of data analysis is provided?
Do you know what you and your employees are paying for prescriptions? Pharmacy benefit plan monitoring and reporting helps brokers and employers to improve performance of the plan when needed.
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Do you have transparent, low-cost pharmacies in network?
By including transparent, low-cost pharmacies in network, members have easier access to cheaper medications, simplified ordering and clear cost savings.
How do you select formularies?
Ensure that your PBM is prioritizing the lowest net cost drug options and most cost-effective solutions instead of rebates that generate profits for them.
Is the PBM independent?
Pressure to show strong profits — such as in the case of a large, publicly traded PBM, or one that has investors — can drastically impact plan design and strategies.
Is the health of your employees the priority?
Is the PBM forward thinking and do they bring a range of options to the table? Do they truly understand the real-world importance of ensuring employees can easily receive their medications in a timely manner at an affordable price?
The vast majority of pharmacy benefits management is run by three large companies. It's an environment rife with hidden fees and opaque revenue streams baked into the model. And, by its very nature, pharmacy is complicated which makes it easy to hide the true cost of medications. This environment won't change until employers start asking brokers the difficult questions. If their answers make you uncomfortable, it's time to consider options that ensure employees are treated like patients and their health is valued over profits. That way, employers can customize benefit plans to affordably elevate employee health.
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A transparent PBM model that puts patients first is not a radical one. But it can feel revolutionary to employers who aren't currently receiving personalized service from plan design and implementation to continuous improvement. The PBM/employer relationship can become a collaboration that helps meet your organization's immediate goals and creates a healthier workforce foundation for the future.
When it's time to reevaluate your organization's needs and your PBM choices, be tenacious. Ask the difficult questions and be adamant that each PBM candidate answers them. As the representative voice of your employees — the patients — don't settle for a PBM which participates in bloating drug prices, skimming negotiated discounts and plundering any difference between what pharmacies receive and insurers are paying.
Look instead for clinically-trained partners taking a patient-first approach to cost management and healthcare.
