Health and Fitness

PBM Questions To Keep In Mind

Choosing a pharmacy benefits manager is an important first step, regardless of whether you are new to the self-funded healthcare market or simply want to make some changes to your current plan. It’s a shame that this title doesn’t get as much attention as it deserves.

For the most part, self-funded companies focus on the cost of surgery or an injury, for example. Adding pharmacy benefits at the end of the discussion is common, or companies simply go with the PBM that their broker recommends.

When it comes to your pharmaceutical benefits plan, though, you deserve a lot of flexibility. And you deserve a partner who will sit down with you and go over the project with you step-by-step, so that you fully understand everything.

When looking into PBMs, be sure to ask yourself these crucial questions.

Do you have any other ideas for lowering drug costs?

Numerous options abound for answering this question, but analyzing your medical records and creating a personalized strategy should be at the top of your list. In order to save money, a self-funded business must comprehend all of the tiers of a pharmacy plan in order to choose the ones that offer the greatest potential for saving money.

What can you do to help us achieve our goals?

When it comes to pharmacy benefits, there is a particular emphasis on the cost per unit. It’s also possible to obtain low value if you’re continuously looking for the lowest possible unit cost. Inquire about how PBMs can provide value to the plan for you and your staff.

To ensure that our staff are receiving the attention they need, what programs have you put in place

While the total cost of your pharmaceutical benefits plan is important, so is the care provided to your employees. Talk to potential PBMs about personnel who require complex or specialized drug treatments while discussing clinical programs.

What kind of customer service can we expect from our staff and ourselves?

The pharmacy industry is always evolving due to the introduction of new pharmaceuticals and pricing systems. With the help of a PBM who will keep you updated on any changes that could affect your plan, you can make any necessary adjustments. Additional aid is needed if your employees are having problems with benefit concerns. Dedicated account managers are assigned to each of our clients to ensure that they receive exceptional service.

We’d like to take a look at your rebate and pharmacy contracts.

In order to be really transparent, a PBM must be prepared to publish the terms of its contracts. It’s possible to find out where and why your costs are accrued by examining the contracts you’ve signed.

It’s best to not let a PBM push something your way without giving you a chance to say no. Determine the ideal PBM for your needs by investigating your options and asking a lot of questions.

It can be difficult to guarantee that health insurance systems are working as efficiently and cost-effectively as possible once they are built and operational

What role does my Pharmacy Benefit Manager have in promoting the health and well-being of my staff?

The primary goal of health insurance schemes is to ensure that employees receive adequate healthcare. Why is the role of pharmacy benefit managers often overlooked in the promotion of health? Every company’s HR Director and CFO want their staff to be happy and healthy at all times.

Health-related services provided by innovative PBMs have a direct impact on the well-being of their employees. By delivering medication therapy management (MTM) treatments and face-to-face consultations to help your employees manage chronic conditions such as asthma, COPD, diabetes, and cardiovascular disease, PBMs can boost your employees’ health. By increasing overall health, innovative PBMs give additional value by influencing the amount of money spent on medical claims.

Employee wellness should be a top priority for your PBM. You may also see a reduction in total pharmaceutical and medical claims as a result of your employees’ benefits.

Is spread pricing available through my pharmacy benefit manager?

“Spread pricing” is a common pricing approach used by several pharmacy benefit managers.

An example of spread pricing is charging a health plan more for a medication than the PBM pays a pharmacy to fill it. Profits accrue to the PBM as a result of this discrepancy.

Many CFOs and HR directors don’t realize how much money this pricing strategy costs the plan, even though it’s standard in traditional PBM. When it comes to pricing strategy, decision-makers are usually unaware of it because it is not explicitly stated in the contract.

Fortunately, gatekeepers can request that their PBM use an alternate price structure. In pass-through pricing, each prescription is billed to the plan sponsor for the exact amount paid to the pharmacy.

It’s possible that your plan is paying spread pricing if the prescription pricing computations are not explicitly defined in your PBM contract. Make sure that your PBM has a transparent pricing structure that actively benefits your employees and your organization.

The rebates I’m entitled to as a member of my PBM are, correct?

PBMs often don’t give plan sponsors rebates from prescription drug manufacturers. Unfortunately, many PBMs are able to make considerable profits by hiding the rebates they accrue. Ideally, your contract with your PBM should specify the amount of rebates that will be paid to your company.

It is important to cooperate with a PBM that explains how it makes money. There is a good chance that your PBM has anything to conceal if they can’t give you an open and honest answer.

Is my pharmacy benefit manager able to provide coverage for specialty medications?

Health care is abuzz with talk about “specialty drugs,” and for good reason. Even though only 2% to 4% of Americans took specialty drugs in 2015. They accounted for 38% of all pharmacy spending.

The purpose of a “prior authorization (PA)” is to temporarily stop a claim so that a healthcare expert can review its medical necessity. For a benefits plan to control the price of specialty pharmaceuticals P.A.s are the most important mechanism used. Your PBM may have a conflict of interest if it has ties to medication companies that give rebates for pricey drugs. In order to protect both the employee and the plan sponsor, ensure that your pharmacy benefit manager has a clear, effective, and transparent prior authorization process.

In certain cases, the most effective treatment for a particular ailment is as expensive as speciality pharmaceuticals. Co-payment assistance programs are offered by nearly every manufacturer of specialty pharmaceuticals. Patients previously unable to purchase their medication can now do so thanks to financial assistance from this program. Your PBM should have a plan to help your employees take advantage of copayment support.

In addition to these two methods, there are many other ways to reduce the rising costs of specialty pharmaceuticals.

There is an average monthly cost of $5,000 for a prescription drug. And the category of specialty pharmaceuticals is expected to grow. Because the stakes are so high, make certain that your PBM has solutions or the whole specialty pharma industry before moving further.

Does my pharmacy benefit manager have to answer to anyone in my company?

Finding a trustworthy Third Party Administrator might be challenging for companies that choose for self-funding (TPA). The TPA’s recommended PBM is used by many businesses to administer the plan.

In spite of its simplicity, plug-and-play can have a considerable impact on plan costs. For the four reasons listed above, pharmacy benefit managers can be an important piece of the healthcare equation. Using a PBM not only benefits your employees’ well-being, but it can also save your company money.

Establish a line of accountability between your PBM and your TPA, so that only your organization will be held accountable for its actions. You may keep track of your PBM’s performance and cost reductions every year by signing a direct contract with them. If you have a direct contract, you can extend or terminate your PBM contract based only on their performance and not on any recommendations from your TPA.

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