Weathering the Rx Storm

By Tim Thomas / On Aug.08.2016 / In crystal clear rx, benefits design, healthcare, health care, health benefits, PBM, Pharmacy Benefits Manager, / Width

A Monthly Blog Series - #1 of 5
 
If you are like most employers today, you are in the midst of a confusing landscape when it comes to managing pharmacy benefits. Making sound decisions on your Rx benefits design can be difficult and costly if you don’t have the right resources at hand. 
 
I thought it would help to provide some information about how to choose the right consultant or firm to assist with these tough decisions. For Rx benefits managers, having a consulting firm with aligned goals that specializes in Pharmacy Benefits can help you and your employees make more informed decisions and get the best value for your money.
 
After speaking at the recent FLHCC Annual Conference, I got a myriad of questions from audience members asking how to get the best value for their benefits spend. 
 
Hiring a pharmacy benefits consulting group can help. At Crystal Clear Rx, we specialize in Pharmacy Benefits, but there are other firms in the marketplace that can also be a valuable resource. Working with one of these informed groups will help to ensure that you are maximizing your Rx spend.
 
In this blog, I want to provide a few pointers on things to look for when you are researching the right consultant or firm to help you best manage your Rx benefits program. There are four main things to look for when researching who to work with: 
 
Ask if they have any affiliations or financial rewards tied to placing a particular Pharmacy Benefits Manager (PBM) with a client. If so, that consultant or group could harm their own book of business by moving clients to a different PBM, so why would they make that recommendation? In the end, you are not likely to get an unbiased approach to your benefits package design. The right consultant can’t take commissions from a PBM. 
 
Lean on a seasoned consultant or firm that specializes only in Rx benefits. They will understand your options best and give you thorough opinions on your best course of action. These specialized firms are not focused on medical spend, or long and short term disability, stop loss, etc. – only pharmacy.
 
Look for a firm that not only has access to current claims data, but also has the ability to use that data to determine the benefit or value to your company’s unique needs (not the PBM’s needs). This ties back to having an unbiased consultant or firm, who is not swayed by PBM incentives. Taking a neutral look at drug spend data and finding areas in which to improve is the role of a good Rx benefits consultant. One recent example of how we use client specific Rx data to discover areas of improvement was when, during a routine analysis, we discovered that a PBM had raised its prices dramatically for mail order. Because we had protective language in the contract and caught the issue early on, we were able to recover the funds quickly without having to wait for an end of the year audit. 
 
Make sure your consultant matches claims data with PBM contractual terms. Those “terms” affect the prices you are quoted as an employer. For example, one PBM may define a “generic” and “brand name” drug differently than another PBM. Definitions can be changed at will to meet each PBM’s needs. This impacts your AWP discounts and guarantees. For that reason, I recommend getting away from using AWP discounts as a judgment of financial performance of a PBM. You are better off looking at what you’re actually spending on a “per unit” basis. 
 
Bottom line – seek out the support of a seasoned, unbiased pharmacy benefits consulting group when trying to make the best decisions on Rx benefits spend for your plan.  The money you are likely to save will far outweigh the time it takes to find the right firm. 
 
In the next blog, I will talk about how to improve your existing PBM contract. In the meantime, please feel free to reach out directly if you have any questions or need Rx benefits advice.