How to move the needle on pharmacy benefits management

All pharmacy benefit managers offer similar services around formularies and manufacturer rebates, as well as clinical programs and network options to manage ingredient cost trends for their self-funded employer customers. There’s also little distinction across their reporting, customer service, account management and claims processing. But there are important differentiators to consider when selecting a PBM partner, according to Cindy Brigman, director of PBM solutions at UMR, Inc., a UnitedHealthcare ASO solution.

They include understanding pass-through pricing agreements and knowing whether the PBM is managing its own rebate contracts, formularies or networks. It’s also helpful to know what’s included in their pricing (i.e., ancillary fees and clinical review or prior authorization charges), as well as an ability to determine return on investment. Another critical area to examine is whether the prescription drug area is carved in or carved out, and if prescription and medical rates are underwritten together. 

Since pharmacy is the fastest-growing segment of healthcare costs, Brigman suggests key cost-management strategies for employers. They include understanding what they’re paying for, as well as implementing a limited or exclusionary formulary across all categories of medication and utilization management programs. Educating health plan members to become better prescription consumers will also go a long way toward improving adherence and clinical outcomes.

In this podcast interview, she explains the concept of real-time accumulators for managing deductibles and out-of-pocket maximums and whether it’s worth investing in this area. Finally, Brigman offers several inventive strategies for managing rising specialty scripts that drive prescription trends, such as using grants from drug manufacturers. 

To listen to more Self-Funding Benefits Talk, click here.