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Making Pharmacy Benefits Transparent and Returning Control to Patients and Employers

Transcarent wants to transform the digital pharmacy benefit experience, enabling self-insured employers and their staff to make more informed choices.


Making the task of understanding pharmacy benefits easier and transparent has never been a strength of pharmacy benefit managers, creating challenges for self-insured employers seeking to do right by their employees. But Transcarent has a vision for how it can change that by simplifying the experience so consumers don’t need to navigate the existing system. In an interview, Transcarent COO Snezana Mahon provided an overview of how the business seeks to embed price transparency and drug information to provide a digital pharmacy benefit experience, enabling self-insured employers and their staff to make more informed choices.

Mahon explained that Transcarent’s approach is based on four principles. Cost is a crucial issue when it comes to pharmacy benefits. So are a formulary and the ability to obtain rebates from pharmaceutical manufacturers.

“Transparency regulates everything that we do as an organization, both transparency with members and with employers. Whether that’s providing full access to rebates that employers are entitled to receive or unrestricted access to view information for what drugs are available, reimbursement information, and ultimately what members are paying,” Mahon said.

Transcarent has pushed aside traditional pharmacy benefit management approaches built on outdated legacy technologies and claims adjudication systems. Instead, Transcarent uses an open, API-based, cloud-based technology that enables consumers to see information in real time that’s related to their benefits. Transcarent members can also proactively receive lower cost recommendations at the time of prescription, then use Transcarent’s platform to make sensible decisions in collaboration with their physicians in real-time, something no other pharmacy solution can provide today. They’re also able to see what a medication costs both prospectively and retrospectively if they’re shopping for medications.

Employers can use Transcarent to build a high-end pharmacy care experience that enables them to choose a formulary design for how drug benefits are administered. It adds flexibility for using retail pharmacies near where their employees live, as well as specialty pharmacies or a mail-order pharmacy. 

The goal is to empower consumers.

“The number one problem today in healthcare is consumers do not trust the current ecosystem,” said Mahon. “So how do we give them the right tools, the right information, and the trusted guidance to be able to make better decisions for their care? We can help them seek alternative medications and cheaper alternatives. We can be fully transparent and provide easy access to care, in order to drive greater adherence, better clinical outcomes and better choices in terms of healthcare decisions that they’re making and the medications that they’re taking.”

Cracking the medication adherence conundrum is critical to lowering healthcare costs and helping people manage their conditions. Although there are many personal reasons why people don’t pick up their medications from the pharmacy, one of the most common ones is that they can’t afford them. An analysis by the National Opinion Research Center (NORC) at the University of Chicago showed that one in four Americans who are struggling to take their medication are disproportionately lower income households. But that doesn’t tell the whole story. Poor medication adherence can affect even people who have well-paying jobs. Some medication costs are astronomical regardless of personal income level. That’s why empowering consumers is such a critical part of Transcarent’s approach.

If you think about the average number of medications that people take, even saving $10 to $15 can make a significant difference. For some members, they can save $50 to $60. It adds up over the course of a year. If the average member is able to save $500 to $600 per year through guidance and raising awareness of lower cost opportunities available for them, it can make a tremendous impact.

Another component of improving adherence is improving health literacy through education, counseling, and guidance. When patients don’t understand how to properly take a medication, or know what side effects to expect, or how to look up that information, that can lead to unwelcome surprises and resistance to taking a drug. Transcarent provides guidance and support for its members, providing direct access to a pharmacist who can talk about the short and long term benefits of medication adherence. A symptom checker within Transcarent’s digital experience enables members to key in symptoms so they can understand what kind of side effects to expect from their medication. It can also trigger a follow-up appointment scheduled with a provider to ensure patients are prescribed the right medication, which could give them a better quality of life and help them to steer clear of adverse effects. The goal is not only to surround patients with transparency tools to access lower cost medications, but also to help members stay on their medication and remain adherent to their care plan.

Biosimilars also have a role to play in Transcarent’s push to improve the pharmacy benefit digital experience. They offer the prospect of cheaper alternatives to prescription biologics. The ability to show and educate patients on price differentials for biosimilars compared with branded biologics will give people the kind of information and insight that enables patients and their families to make more informed choices. This information and guidance is what self-insured employers need to reduce their costs.

According to Mahon, there are several key drugs and biologics that are losing exclusivity in 2023. HUMIRA is a key one and there are several others that are going to be able to provide more optionality where brand exclusivity will expire in 2023.

“Right now there’s 7,000+ products in the specialty drug and biologic FDA pipeline. Most of those medications are specialty medications that will get approved sometime between 2023 to 2025,” Mahon said.

By providing these tools, employers are able to deliver and shape the future of benefit designs and incentives that consumers can engage in and be more empowered to take better care of themselves and their families.

Transcarent also transforms the prior authorization process. Typically, prior authorization is predicated on the benefit design in the formulary that an employer chooses, according to Mahon. 

“I would say roughly in any given formulary in the country for most employers, maybe 20 to 30% of medications have either a clinical prior authorization, a step therapy, or quantity level limit that is being applied. In this scenario for clients who choose us to also be their claims adjudicator, not only are we delivering the superb pharmacy care experience, but we’re also adjudicating the claim on behalf of the employer,” Mahon said. “It will still trigger the associated prior authorization step quantity level limits that may be associated with that drug, but we’re able to contact the provider, get the patient to get their medication in a very quick turnaround time, leveraging the information that is available to us. But with our prior authorization process, it may never even need to occur retrospectively because you have already addressed drug alternatives, lower cost options at the point of care vs. at the point of sale at the pharmacy counter, where it doesn’t even need to get to that point and so we are able to support both fronts.”

Transcarent wants to bring the longitudinal holistic pharmacy care experience to health and care and give more power to consumers in the decision-making process, so they can be a critical driver in care delivery and consumption.

Photo: Who_I_am, Getty Images