MedCity Influencers, Payers, Employee Benefits

Maintaining affordable access to prescriptions in a post-pandemic world

PBMs who are transparent, offer formularies that reduce wasteful spending and have experience in specialty pharmacy are better poised to meet the needs of plan sponsors and ensure the most affordable drug coverage options.

As the Covid-19 pandemic continues to evolve, pharmacy networks have largely delivered against the challenge to meet critical health care needs. Pharmacies across the country remain open to accommodate patients, and anticipated drug shortages and supply chain concerns from early in the pandemic have not come to fruition.

As patients start to head back to doctors’ offices for routine care and elective procedures, there may be a pent-up demand for prescription drugs as people start new medications and adjust their current ones. In this time of global disruption and change, it’s imperative that plan sponsors have a transparent and accessible pharmacy benefit manager (PBM) to manage their pharmacy benefit and ensure plan members receive affordable prescription drugs. For organizations who don’t have a strong partner or are experiencing current issues that have exposed a need for more transparent coverage, here are three ways to reevaluate your pharmacy spend and ensure you and your members have more affordable pharmacy benefits:

Understand PBM business models
PBMs play a significant role in how well plan sponsors such as employers, health plans and government entities can maintain and reduce their drug spend. Plan sponsors should always make an effort to understand a current or potential PBM partner’s business model, as it determines all other decisions an organization can make regarding its pharmacy benefit, including how much data it can access or what financial metrics it needs to meet.

Two main PBM models are available for consideration: traditional and pass through. Both models may claim to be transparent; however, a traditional model is less visible about its business practices and offers volume discounts and high rebates. A true pass-through model passes 100% of all pharmacy discounts (“zero spread”) and 100% of all rebates back to the plan sponsor, and its business practices are auditable, making it a more transparent option. Each model has important differences in how they operate, and plan sponsors need to determine which will best fit their company’s needs. In today’s uncertain times, having a transparent PBM who will identify areas for cost savings and grant access to all claims data is essential for ensuring an organization doesn’t overspend.

Look for formulary and utilization techniques that reduce wasteful spending
Formularies, or drug mixes, play an essential role in an employer’s overall plan cost, but it is difficult to quantify and is often overlooked in the PBM evaluation process. It’s important to look for partners who offer cost-effective alternatives, such as generics or less expensive brands, to drive lower net costs. With lower average wholesale prices, plan sponsors can achieve substantial rebates without paying more, ultimately lowering per member per month (PMPM) costs, which is a strong metric to identify a plan sponsor’s “all in” pharmacy benefit expenses. A robust formulary should also include techniques for reducing wasteful spending, which helps ensure plan sponsors aren’t spending more money than they need to.

Don’t overlook specialty pharmacy benefits
Specialty medications are expected to exceed 50% of drug spend over the next three years, so it’s no surprise that this area should be a primary consideration for pharmacy benefit management. Members who use specialty medications should be receiving personalized pharmacist support to make sure medications are being used appropriately, side effects are being managed, and individuals are receiving condition-specific support for their health needs.

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A Deep-dive Into Specialty Pharma

A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.

Furthermore, there are nuances with specialty medications, as some require a clinician to administer them, which may fall under the medical benefit instead of the pharmacy benefit. Channel management strategies can help control specialty spend and generate savings by shifting the coverage of certain drugs from the medical benefit to the pharmacy benefit. Work with a partner who is experienced in specialty pharmacy to ensure the unique needs of members are met, while costs are better managed.

Ultimately, PBMs who are transparent, offer formularies that reduce wasteful spending and have experience in specialty pharmacy are better poised to meet the needs of plan sponsors and ensure the most affordable drug coverage options. With heightened pressure from the pandemic, PBMs have an increased expectation to be flexible, responsive and work with the best interest of plan sponsors and their members in mind.

Photo: Stas_V, Getty Images




Brent Eberle is the Senior Vice President and Chief Pharmacy Officer at Navitus Health Solutions. He also serves as the General Manager of Lumicera Health Services, a wholly-owned Navitus subsidiary and full-service national specialty pharmacy.