Pharmacy benefits are one of the most important employee health benefits that a company can offer for recruitment and retention. But healthcare is complicated. Prescription drugs and pharmacy benefits managers (PBMs) are at the center of a world populated by pharmacies, prescribers, health plans, brokers, consultants. So how do you choose a PBM?
When you’re looking for a PBM contract, you need to understand what they do and how it will affect your bottom line. It’s a journey where you need to speak to specialized languages of pharmaceuticals, medical care, health insurance, and government regulations.
Integrated Prescription Management (IPM) understands the different needs of stakeholders – employers, providers and members. PBMs are at the center of a world populated by those stakeholders and others, including health plans, third-party administrators, brokers, consultants. We can be your guide and translator.
Employers need to balance the healthcare needs of plan members and the high cost so many medications. Providers want to deliver care and make a living. Members want to get prescriptions filled at the lowest possible out-of-pocket cost. IPM is a PBM that believes stakeholders should be able to make informed decisions through collaboration.
We will help you understand what you need to know about PBMs and their services, and what questions you should ask when choosing a PBM.
Here are some of the discussions you should have:
Relationship and responsiveness
Consolidation in the PBM market means that it is dominated by three mega-PBMs, who may have a take-it-or-leave-it attitude, particularly for small employers.
- Do you feel like you are getting a sales pitch about available services, or that you are engaged in collaboration to determine how you can benefit?
- How much control do you have over benefit design?
- Does the PBM seem to have your interests in mind?
Pricing, rebates & discounts
Some PBMs are more concerned about their relationship with pharmaceutical manufacturers than with their clients because they benefit financially through rebates. This can influence whether a brand drug is placed on the formulary.
- How are drug prices set?
- Will the PBM be transparent about spread versus passthrough pricing?
- How does the PBM demonstrate its commitment to lowest net cost?
Pharmacy networks may be broad, national networks to provide maximum access for members. But a smaller “narrow” network may be just as good for a regional or smaller business.
- Do you have options when needing flexibility on pharmacy networks?
- Are you able to carve out specialty drugs?
Utilization management is a large piece of your benefit design to contain costs. Knowing and understanding your benefit options will help you in the long term.
- What will your PBM do to monitor and control utilization?
- What will your PBM do to encourage medication adherence to increase patient safety and minimize waste?
- Does the PBM provide a consultative approach to explain the pros and cons of benefit design structure?
Mail order / home delivery
Most PBMs should offer a mail and/or home delivery option for the benefit plan.
- Does the PBM own the preferred mail order/home delivery pharmacy, and if so, what are the benefits of this?
- What options do you have when choosing a mail order pharmacy?
Specialty drugs account for half or more of drug spend and accounts for 1-2% of claims. They are also 10x more expensive than non-specialty drugs.
- How does your PBM help with specialty drug savings?
- Does the PBM own a specialty pharmacy service, or possibly an infusion network, and if so, what are the benefits of this?
- Is the PBM committed to biosimilars?
For more information or a free claims analysis, contact us today at firstname.lastname@example.org.