Selecting a new pharmacy benefits manager (PBM) can feel overwhelming. It might be tempting to just look at a spreadsheet to make the decision. However, the final figures may not reflect the lowest overall health care costs and don’t reveal the type of care or service your company or your plan members will receive.
We’ve combined a checklist of 10 crucial factors to consider when PBM shopping. To get an effective plan that meets your goals, offers quality care for employees, and sets you up for long-term success, discuss these items with prospective PBMs.
1. Ask about Access to Pharmacists During Plan Design
Many parts of your plan impact health outcomes, the amount of member disruption, and cost. Making the best choices for formularies, step therapy processes, and options for specialty medications require some level of clinical understanding. Having a pharmacist available to answer questions and explain options during plan design results in better employee health and cost savings.
2. Check the Depth of Data Reporting
How often will you receive reports and what data will be included? Will the data show ROI and identify emerging trends that should be addressed? Can you request additional reports as needed?
3. Inquire if Plans are Customized
Each company has unique goals and employee health needs. Pharmacy plans should be designed to meet those specific needs. Be sure your PBM can show how proposed solutions meet your goals.
4. Find Out if the PBM is Independent
If a PBM is publicly traded, has investors or is planning to sell to investors, there is extra pressure to show strong profits. This can impact strategies and plan design. An independently owned PBM is better able to balance patient outcomes and cost savings.
5. Understand Pricing and Rebate Numbers
Can the PBM show you what price they pay the pharmacy for medications? Avoid spread pricing, which charges employers a higher price for medications than what the PBM pays pharmacies.
You should also look for a PBM that passes through the entire amount of drug manufacturer rebates they receive. Many PBMs will subtract an administrative or distribution fee from rebates. Also ask for all form of remuneration a PBM may receive. Some PBMs claim to pass through rebates but keep other forms of compensation from manufacturers or rebate aggregators.
6. Explore Plan Member Satisfaction
The member/patient experience matters. If your employees are frustrated with their pharmacy plan or the service they receive, it can impact overall employee satisfaction and increase the time spent trying to solve issues. Ask about member satisfaction ratings, call resolution rates, and the average length of time for members to reach a live person.
7. Define Contract Terms and Fees
A PBM dedicated to integrity should be able to explain any part of the contract to you. If the contract is sprinkled with fees, be sure fees are clearly defined so you can calculate how they might reduce potential savings.
8. Consider Solutions for Specialty Medications
Specialty medication costs, even from just a few claims, can easily make up more than half of your drug spending. Look for a PBM that offers several solutions and provides price modeling and patient impact analysis associated with each option.
9. Gauge the Rebate Strategy
Ask the PBM how they balance cost savings and patient care. Indicators of a balanced approach include a generic utilization rate above 85%, step therapy protocols, and wellness solutions to lower drug spending. Avoid a PBM that chases rebates, putting brand name drugs first to achieve the highest possible rebates. This strategy rarely results in the lowest net cost or outcomes that reduce overall health spending.
10. Discuss Tools to Reduce Disruption
Review the PBM’s implementation plan and timeline. Be sure it includes steps to reduce disruption for your plan members. The earlier you can share current claims files, the more lead time the PBM will have for communicating with any plan members who may be affected by formulary changes.
Learn More in Our Webinar: Closing the Deal
View our webinar recording to learn more about PBM selection. Time to Close the Deal: Choosing the Right PBM Partner
To learn more about pharmacy benefit solutions from True Rx Health Strategists, contact us at sales@truerx.com. We will schedule a time to discuss your challenges and goals.